Outside Addis Ababa’s Black Lion Hospital is a crush of people. Some sit on red plastic chairs, others lie on a cement pad stretching from the emergency room’s metal door. Family members tend to mothers and brothers, or try to reason with the security guard leaning halfway out the door’s missing window. He looks blankly past them, sees me, swings the latch and I pass.
The sicknesses I see in the tin room in Ethiopia are different from the ones I see in the ER at St. Michael’s in downtown Toronto. It’s not just the nature of the illnesses, but the severity: You must be nearly dead, or briskly on your way, to get admittance to the public ER in Addis. While some people in Toronto bypass their family doctor and come to the ER when something “doesn’t feel right,” in Addis people are there because they have no other choice.
When Toronto Life published that St. Mike’s has an “express ER,” my colleagues and I groaned. Only two years ago, we thought 200 patients a day was busy. Now 250 is common. We add shift after shift, and our roster of physicians grows. But unlike Addis Ababa, it’s not to treat those lifted seemingly lifeless from a taxicab. Canadian patients are lined up looking for help with hemorrhoids, insomnia, prescription refills, the common cold – and often to standing room only.
This is one time, in a society that has forgotten how to do it, when waiting is good. If you’re in the ER and you’re not hurried to the front of the line, you’re lucky. If people are rushing you in, well, then you should worry. Just like outside that windowless metal door in Addis, there’s an invisible process at work: The sickest goes next. Not the richest or the most powerful, but he or she who hurts most. This ethic illuminates the best part of our human spirit, as brightly as the red letters do our emergency departments that never close.
In Canada, we’ve got a habit of judging the success of our health-care system by how long we wait. The Fraser Institute, a pro-private-health-care think tank, releases reports on wait times for elective procedures, concluding that people are waiting longer than ever, and citing dollars lost to quantify that adversity. We live in an age where everything that matters is assigned a value to the nearest nickel. Unfortunately, what happens after the person reaches the front of the line is given less attention. Did the knee operation help the person climb stairs more quickly? Did the cataract removal sharpen someone’s sight, or lead to the discovery that the blurriness was from something else?
Our population is aging, and that means more painful knees, more cataracts to cloud an otherwise bright day. As patients turn to the hospital for relief, the strain on the system will grow. Old habits die hard, and treatments known to have limited utility persist. The Internet has replaced one’s family physician as a main source of advice, and people Google their symptoms, and without the benefit of experience, note rare cases and insist on an MRI. An already long line stretches out the door, and into your home.
But there are some encouraging steps that will at least make the wait more efficient. Palliative teams and mental-health workers are visiting people’s homes, moving to the periphery care once found only in hospital. More medical work is being done by non-physicians, with comparable outcomes. And Choosing Wisely, an international endeavour started by the U.S. National Physicians Alliance, asked medical societies to identify five tests or procedures unsupported by sound evidence that should be avoided (such as imaging for non-specific back pain, for instance, or CT scans in minor head injuries).
The best way to manage a wait is to avoid it. To encourage wise choices, a family physician remains a remarkable steward, not just to navigate an increasingly complex health system, but to keep you well. Develop a relationship with one, so you don’t come to the ER to jump the queue to a specialist or MRI. If you do, do not expect to be admitted if you can be investigated or treated safely at home; hospitals can make you sicker. Don’t expect refills of opiate or sedative prescriptions; those medicines have so many side effects, you need an expert to help navigate them. Chronic conditions are difficult to manage in the ER, because we only get to see you once.
Above all, if you’re unsure whether yours is an emergency or not, come to the ER. It has the best logic of any place I know, because we take anybody, any time – the ill, the tired, the afraid, the anxious. But, as in Addis Ababa, the sickest first, then everyone else in the order they come.
James Maskalyk is an emergency physician at St. Michael’s Hospital in Toronto. His second book, Life on the Ground Floor, will be published in 2015 by Doubleday.
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