Three Nights in Emergency

As a second year medical student I am still unsure of the field of medicine that interests me the most. Shadowing physicians is a great way to get a taste for different specialties, and that is just what I’ve been doing. Emergency medicine initially appealed to me because it seemed to be a very fast-paced, hands on specialty that deals with acute crises. However, as I spent some time in the emergency department of a local hospital, I found it to be rather different from what I expected. Three patients in particular stand out in my memory. Incidentally, all of them were brought in by the police.

There was one woman who was probably in her forties or fifties; she looked really unkempt and disheveled. This patient lost consciousness at a bar, where she had been drinking for the past few hours. When the doctor saw her, she was already conscious and alert. She was really angry at the policemen for bringing her to the hospital, because she felt she had no business being there. In a way, I agreed with her. She was still intoxicated and confrontational, but there was little for us to do. She may have needed support, maybe addiction treatment, but that is not the role of the emergency department. She had no injuries and seemed of sound mind, even though she was swearing a lot. The doctor thought the least we could do was get her home safe, but even that proved difficult, as the taxi drivers refused to take her due to her demeanour. In the end she left on her own.

There was a man who was older, probably in his sixties or seventies, seated in a wheelchair and covered by a blanket. He looked really ill and emaciated, was homeless, and there was a strong odour of alcohol about him. I got the task of interviewing him, but I was able to get very little information. The answer to most questions seemed to be “I don’t remember” or “I don’t know”. He was not aware of any chronic or acute medical conditions that he had. All he could really tell me was that his leg really hurt and he couldn’t walk. He still had his sense of humour though; to my questions about his bowel habits he raised his eyebrows in mock outrage and said “do I look like I have trouble with that?”. As the physician looked at the records of this man’s previous visits, she noticed that this patient has been here just last week, and very often before that, too. According to the records, this patient likely had an underlying cancer and dementia. It seemed clear to me that he needed continuing care, yet he was admitted and discharged several times in the past few months, sleeping on the street or in the shelter in between hospital visits. The doctor, who understandably felt really bad for the man, got me to bring him some food, and then she admitted him to medicine, once again.

There was a young woman, in her late teens or early twenties, who was brought in because of suicidal ideation. A friend of hers called the police. Before we went to see her, the physician told me he has seen her here many times in similar circumstances. There was police waiting by the room where the patient was held, and she still had handcuffs on, even though she seemed perfectly calm. The physician got them to remove the handcuffs and talked to her for some time, while I listened. The patient seemed sure that she was going to be safe if she was allowed to leave, and both her and the physician agreed that nothing positive was going to come out of her being admitted - after all, this has happened several times before, and the patient claimed the experience at the psychiatric ward was not helpful in the past. She got some juice, a taxi voucher, and went to the shelter she was staying at. I wondered how much time would pass before she would find herself in the emergency department again.

Even though these are three distinct patients, I saw several others like them in my short time in emergency. These patients belong to vulnerable populations and need ongoing regular care, yet they don’t get it. Instead, it seems, they end up in the emergency department on a regular basis, where the doctors chat with them, give them some food, and send them on their way. In the winter, especially on cold nights, some physicians will often keep these patients at the department for longer if they know there’s nowhere else for the patients to go. I admire the seemingly unlimited reserves of empathy and understanding of emergency docs; I also noticed how knowledgeable they are about resources available in the community - they know which shelters to call and know the ones that won’t take patients with substance abuse issues. And yet, it seems like a visit to emergency is an expensive and an ineffective way to address these patients’ issues. For many of them, a lot of problems would be solved by stable counseling, and/or housing, or simply a dedicated family doctor. Although these experiences did not discourage me from pursuing emergency as a specialty, I certainly view it in a different light now. It is really a specialty that combines primary care, emergency care, psychiatry, and social work into one. 

Polina Tsybina, Western University