Dr. James Wiedrick: I'm an ER physician, and Canada's health-care system is critically ill

It is past time to begin an overhaul, starting with the Canada Health Act.

By: Dr. James Wiedrick

It seemed surreal. I was trying to refocus after a medical procedure on the seventh hour of a summer weekday emergency-room shift. One of my nurse colleagues yelled that a young adult male with major burns had just arrived and that I needed to drop everything and come outside. Someone shouted, “Hey doctor, should we divert him and his driver immediately to the regional ICU hospital? It’s just one more hour away!”

The nurses, the patient’s coworker, and the paramedics all looked to me — the solo ER physician on duty at our 30-bed hospital in Nelson, B.C. For the first time in my 25-year career, I froze. My brain felt like a pinball machine on tilt. The idea of simply redirecting the driver had a certain appeal and even a surface logic. Why? Because the man was desperately burned, I was already managing four other critically ill patients, and I had been run off my feet all day. Instead, I managed to say, “Get an IV,” and “I need to think.”

I really did. There were too many sick patients and not enough time on my solo-coverage shift. The buzz in my brain was real. Yet my triage instincts told me this patient needed immediate attention, not in an hour. He required IV fluid resuscitation, analgesia, and definitive airway management. His facial burns put him at high risk of airway swelling and closure. None of those issues could wait.

I gave my head a shake, told myself to snap out of my stupor, and that I didn’t have time for a pause. The on-call anaesthetist was paged for backup, and this unfortunate burn victim became my priority for the next 30 minutes. I spoke to him calmly, took a history, obtained consent, induced a procedural coma, and intubated him to protect his airway while we arranged urgent transport to the Vancouver burn unit — the correct and best destination.

When an emergency-room doctor on the television show The Pitt has “a moment,” it usually makes for good drama. But no Canadian patient wants to hear that the ER physician on duty froze for a minute. Maybe it’s time to retire? At 54, I have slowed a beat. Still, my experience helps me be more decisive than younger colleagues. The reality is that my incident is just one story among many shared throughout the ER world. With the shifts we work now, it takes only one extra sick patient for the local ER to become overwhelmed.

And that’s if the ER is even open. Dozens of times in the last five years, primary-care hospitals in the B.C. Interior have had to close their emergency departments for lack of physician coverage or adequate nursing staff. I have helped out in Grand Forks, Oliver, and 100 Mile House. Given their geographic catchment areas, these sites should not be closing — yet their communities periodically face total unavailability. One closure triggers a domino effect: the next facility is instantly overwhelmed, whether that is Penticton, Kamloops or Kelowna.

The truth is that our national medical infrastructure is not keeping pace. The Nelson ER is one of the newest (only 15 years old) and most spacious rural emergency departments in the province, and still every bed was occupied with long waits that August day. In fact, since pre-pandemic baselines, our daily ER visit numbers have risen by 40 per cent. Why? The population we serve has grown without careful planning (thanks, federal government), the average patient is older and sicker, and data have shown higher rates of vascular events such as heart attack and stroke in the interval following COVID-19 infection.

I have argued for years that we needed a fourth daily physician shift in our ER on at least 50 per cent of the days of the year. We did not have that last summer; we do now. But a curious phenomenon is observable: doctors are “fried” and worn down. Instead of three longer fee-for-service shifts covering the 24-hour department, we have gravitated to four shorter salaried shifts. Our actual capacity has increased only marginally.

The battle against this overwhelming tidal wave of demand is captured in compelling detail by Canada’s best-known emergency physician, Dr. Brian Goldman, in his newly published book Casino Shift. The book is a raw account of the trials in his Toronto ER. I found it painful to read — because it mirrors my own work anxieties so closely.

The Nelson ER is actually in better shape than most urban hospitals. Our maximum waits are about six hours, compared with the 12-plus hours I hear about elsewhere. We have admitted patients boarding in treatment beds, but not to the same degree as our referral centres. Thanks to community fundraising, we even have a 15-year-old CT scanner that we have needed to replace for five-plus years — perhaps that will finally happen this summer (after years of delay, I am not holding my breath). Modern emergency medicine relies heavily on CT imaging, yet I marvel at how few B.C. sites have a scanner. And I have not even begun to address the scourge of methamphetamine use or the heavy burden of psychiatric illness in our communities.

Troublesome stories continue to emerge from major metro hospitals in Winnipeg and Edmonton, with tragic waits and outcomes. Every mid-sized city ER is continually overwhelmed. Recently, my Alberta-based father spent an entire day in the local ER with a fractured skull and subdural hematoma — without the luxury of a stretcher.

So what is the answer to our overwhelmed ERs and infrastructure deficit? Some say we must spend more money. OECD (Organization for Economic Cooperation and Development) dashboards of national health-care performance expose that answer as overly simplistic. Our monolithic, slow-moving, bureaucracy-bound system lacks the nimbleness to meet practical realities. Every government intervention is, in effect, a market distortion. I used to try to drive change from inside the health-authority hierarchy, but I have since realized the futility of that approach.

I am now convinced we need a complete system redesign, starting with the Canada Health Act. We should add two new principles — timely access and patient-focused funding — to the existing ones: public administration, portability, universality, comprehensiveness, and accessibility.

I am no longer sure what value exclusive public administration delivers for us in the 2020s. The truth is that private-public mixed systems in Europe function far better. Let’s demand and expect better. Why continue with a model that no longer serves us? People are suffering and deserve an actual nationwide debate on system redesign. The future possibilities should bring us hope and the care we all need — not the present dismal status quo.

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In this article, Dr. Wiedrick refers to The Casino Shift, a book by Dr. Brain Goldman. Tonight, in the latest episode of On The Line, Dr. Goldman joins Matt Gurney for a discussion of that book and his own experiences. Stay tuned for that here at ReadTheLine.ca.

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