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加拿大急诊室危机每年或致1.5万人死亡！医生都撑不下去了

温哥华港湾1 贝壳 2024-07-19 

让 Kerstin de Wit 博士和她的研究团队感到震惊的并不是急诊医生们在倦怠调查中对每个陈述的评分（从“从未”到“每天”）。

让他们感到震惊的是医生们在最后一个可选的开放式问题中的回答：“关于您的经历，您有什么想告诉我们的吗？”

“这太可怕了。20年来最糟糕的一次。没有光，只有黑暗，”一位医生说。

另一位回答说：“环境正在慢慢淹没我，越来越难以呼吸到新鲜空气。在急诊室工作了 23 年之后，我想我再也坚持不了一年了。”

“我受够了。”

'I don't think I'll last': how canada's emergency room

调查发现，自 COVID 疫情发生以来，急诊医生的情感耗竭和去人性化——即缺乏对他人的同情能力，一种因感觉身心俱疲而产生的情感疏离和麻木——水平有所上升，而这种情况对患者的后果可能是灾难性的。

金斯顿皇后大学（Queen's University in Kingston）急诊医学教授兼急诊医学系研究主任 de Wit 说：“最令人震惊的是声音是如此一致。”

“并不是说我们收到了好坏参半的反馈。98%的评论都是关于负面经历或感觉非常绝望的，”她说。

“这真是一个重击。”

这项研究调查了 2020 年 12 月加拿大急诊医生的倦怠率，以及 2022 年秋季同一批医生报告的倦怠率，当时急诊室同时受到了呼吸道合胞病毒和 COVID 的冲击，孩子们返校后，这些病毒又如潮水般涌向急诊室。

de Wit 说：“病毒和 COVID 简直疯了。”精疲力竭的医生和护士们加班加点。家属们面临着悲惨的等待时间。据报道，有人在担架上被折磨了好几天，或者在等待被转移到楼上的病床时死亡，这些故事令人毛骨悚然。

如今，急诊室里仍然挤满了等待转入病房的病人。在安大略省，5 月份的平均等待时间为 18.8 小时。在政府规定的 8 小时目标时间内被转移到病床上的病人不到三分之一。急诊科报告的“寄留”人数创下了历史新高。“寄留”是一种非人道的做法，即在病人入院后，由于楼上没有空床位而将其安置在走廊或临时空间。据 CTV 报道，在新斯科舍省，急诊科去年的死亡人数创下了六年来的新高，从前一年的 558 人增加到 2023 年的 666 人。

加拿大急诊医生协会的一个特别工作组称，有些人因尚未确诊的心脏病发作或中风而等待数小时，这些疾病需要时间敏感的治疗，如破除血栓和恢复脑部血流的药物，但“在混乱中被忽视”。

据发表在《加拿大急诊医学杂志》上的一份报告称，如果最近公布的英国每周因急诊人满为患导致的死亡人数分析在加拿大成立的话——鉴于加拿大的拥挤统计数据比英国还要糟糕，没有理由不成立——估计每年有 8000 到 15000 名加拿大人因医院人满为患而死亡。

急诊科医生詹姆斯-沃勒尔（James Worrall）和保罗-阿特金森（Paul Atkinson）写道：“值得注意的是，加拿大很少讨论这一超额死亡率。”

“医生、政治家和媒体经常把医院拥挤和急诊室病人等待时间过长说成是一种不便，而不是致命的因素。”

据《蒙特利尔日报》（Le Journal de Montréal）报道，去年 8 月，一名 73 岁的妇女因动脉瘤在魁北克省乔利埃特（Joliette）的一间急诊室等待 17 个小时后死亡。魁北克省卫生厅长克里斯蒂安-杜贝（Christian Dubé）今年 3 月在议会回答反对党提问时说，这名妇女的死亡是分诊错误造成的，“非常不幸”。

安大略省患者监察专员在2022/23年度收到了4300多份投诉，比上一年增加了33%，是自2016年设立以来的最高数字。医院占了投诉的一半。在与急诊有关的投诉中，“最令人担忧的是越来越多的投诉称，严重的健康状况未被识别或治疗，导致患者离开医院到其他地方寻求治疗，或造成严重后果，包括患者死亡。”

报告包括一名女性在急诊室等待期间流产，并在卫生间内大出血几乎晕倒的案例。另一个案例中，一名患者在一周内多次因呼吸急促和胸部沉重被送往急诊室，但每次都被检查后送回家，最后一次急诊访问不到24小时后被发现死亡。

但患者监察员指出，急诊人员面临的压力一直没有减缓，这是床位和人员短缺造成的后遗症，COVID 又加剧了这一问题，过去三年来，家庭医生危机、看专科医生的延误、不协调和分散的医院流程以及需求更复杂的老年患者等因素又使情况变得更糟。急诊医生在椅子上或候诊室里为病人做检查。走廊医疗已经成为常态。有些人在储藏室里接受治疗。越来越多的急诊医生不得不告诉病人：“你得了癌症”，因为他们在对可疑症状（如突然出现的令人费解的体重减轻或可以摸到的肿块）进行检查时，要面临长达数月的等待。医生们告诉 de Wit 的团队，急诊室已成为该系统失败的“垃圾场”。

研究人员在《急诊医学年鉴》（Annals of Emergency Medicine）上写道：“最普遍的主题是医疗保健系统已经崩溃。”de Wit 说：“他们觉得需要几十年才能恢复。”

接受调查的医生描述了“可怕”和“不安全”的工作条件、精神伤害、悲观情绪和无力感。在 2022 年，59% 的医生报告了高度情感耗竭，高于两年前的 41%；64% 的医生有高度去人性化，高于 53%。

在去人性化的情况下，医生可能显得冷漠无情。de Wit 说：“病人很容易察觉到这一点，这很令人不安。”在去年安大略省的急诊经历中，缺乏敏感性和关怀是最常见的投诉之一。de Wit 说，在大多数去人性化严重的情况下，“我认为人们只是努力在水面上挣扎。”

而水位在上升。一位接受调查的医生说：“我已经厌倦了人们谈论职业倦怠。我感觉到的不是职业倦怠。这是精神伤害。无论如何‘自我护理’都无法让我的病人在今天及时进入手术室，或者让他们有床位……这是因为我无法提供我受过训练提供的、患者需要和应得的护理。”

de Wit 说：“医生职业倦怠是一个巨大的患者安全风险。”它增加了医疗失误的风险--用药错误、误诊和草率决策。她说，职业倦怠就像一种身体疾病。“你没有发挥出最佳水平；你感觉不舒服。”她说，这还有可能进一步消耗劳动力，因为除了优秀的护士之外，加拿大正在失去优秀的医生，“比如，那些把自己的职业生涯奉献给急诊医学的真正优秀的人，他们已经决定不再想做这个了。”接受调查的医生年龄中位数为 42 岁，男女人数大致相当。

全加拿大有成千上万的急诊医生。我们无从得知 2022 年参与调查的 381 名医生是否能代表该领域的所有从业人员。

但 de Wit 担心，“作为一个职业，我们已经成为受害者。”

这是一个复杂的问题，没有简单的解决办法。de Wit 说，医院的病人多于床位，而家庭医生的数量远远不能满足人口的需求。缺乏长期护理床位和家庭护理——所有这些都给急诊带来了压力。

de Wit 说，在危及生命或肢体的紧急情况下，“我们会把病人从抢救室中转移出来，”de Wit 说，“但搬出去的人现在却在走廊里。当人们被分流到候诊室，但却需要等待 12 个小时时，就会出现其他潜在的危险。如果情况有变，没有人为他们提供帮助，或者他们的病情恶化没有被发现，这就会成为一个更严重的问题。”

医生们说，这往往只是一个又一个的“创可贴”解决方案，比如增加更多的走廊空间，或者“超负荷协议”，而不是想办法从长远解决危机。

de Wit 说：“如果急诊系统崩溃或失灵，就会威胁到加拿大人的整体健康。我们是进入医院的主要入口。如果我们不能在急诊科做好工作，如果我们不能做好诊断、治疗和分流工作，患者将遭受巨大的痛苦。”

'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

Author of the article:

Sharon Kirkey   Jul 19, 2024   

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 Press

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.Why Canada imposes a quota on how many doctors can graduate each year

If you haven’t heard, Canada has a pretty severe doctor shortage right now. We’re talking six million Canadians who don’t have a family doctor and have to hang out in a hospital waiting room for most of the night any time they want to access some “free healthcare.”

 

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.

 

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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.”