Rethinking the Role of the ER: Dr. Joel Lexchin on ‘Life & Death in the Emergency Department’

On Monday, November 30th, the Health Studies Students’ Union invited Dr. Joel Lexchin, a distinguished physician and professor, for an interactive talk open to all students and faculty. Dr. Lexchin, an expert on all things ER-related, has worked as a UHN emergency department doc for over 30 years and is also a lecturer at the School of Health Policy and Management at York University. He has authored over 140 publications about pharmaceutical policy issues, drug regulation and promotion, and access to medications in developing countries. His depth of experience on these issues has led him to serve as a consultant for various international government institutions and transnational health bodies such as the World Health Organization.

During his talk, Dr. Lexchin revealed the reality of emergency room care and addressed many of the misconceptions about ER dynamics, such as the true cause of long waiting times and the many functions – both medical and social – of the emergency department. He also raised ethical questions about privilege and discrimination, which engaged the audience in a fascinating back-and-forth discussion, and questioned the responsibility of physicians to be more vocal on social issues.

Dr. Lexchin began by painting a sobering picture of the “real-life” ER – which is nothing like what we see on TV. In real life, things move a lot slower. People don’t come in with as many life-threatening injuries and the outcomes are not necessarily as good – in other words, there aren’t as many “miracles.” He pointed to a study which compared ER survival rates for cardiac arrest on television with those that occur in real life: TV trumped real life by more than double, 67% to 30%, respectively. He talked about how the portrayal of these miraculous survivals on television actually skews the perception of success for patients’ families. It creates unrealistic expectations in healthcare that often affect how people tend to communicate with ER staff.

On that note, visits to the emergency room are not usually for people experiencing cardiac arrest. In fact, only about 1 in 200 people coming into the ER need backs-to-the-wall, high-octane resuscitation: that’s just 0.5% of all ER patients. “Most days,” Dr. Lexchin explained, “We don’t save lives, we just make people feel better.”

According to the Canadian Triage and Acuity Scale (CTAS), which categorizes the criticality of incoming patients on a scale of 1 to 5 (with 1 indicating the need for resuscitation and 5 being non-urgent), more than half of all ER visits are deemed to be a 4 or 5. However, Dr. Lexchin was quick to point out that this does not mean there is nothing that can be done to help them. Dr. Lexchin furthered this notion by depicting the ER as a modern day almshouse. Historically, almshouses were established to provide housing and social services for the poor and the sick. As these almshouses were eventually replaced by welfare programs and modern hospitals, emergency departments were tasked with taking on certain social roles. In fact, the ER still shares certain features with traditional almshouses in the most important ways, such as always being open, not turning anyone away, and providing “safety net social services” such as clothing, food, beds and warm shelter, prescription drugs, and transit fare – to name a few. When conceptualizing the ER in this way, it becomes clear that the ER serves a much greater purpose than simply treating acute medical problems.

Does providing these social care services affect ER wait times? According to Dr. Lexchin – no. And many studies have corroborated his sentiment; the off-load delay (from ambulance to ER bed) actually has little to do the total number of people in the ER, and everything to do with a lack of bed space in hospitals and the lengthy process of admitting patients in general.

Appreciating the full extent of the ER’s role as central to social welfare is even more fitting when taken in context with the most common diagnoses seen in frequent ER users: anxiety, alcoholism, schizophrenia, and drug addiction. People from low-income neighborhoods are also among the highest users of ER services. The correlation between frequency of ER visits, chronic mental illness and substance abuse, and socioeconomic status are telling of the depth of social determinants of health and more importantly, reflective of a gap between social policy and medical care that needs to be addressed.

Dr. Lexchin’s talk was deeply informative and thought-provoking; he brought to light the intersection of human compassion and medicine in a captivating way, which effectively redefined the role of the ER in the minds of every member of the audience.

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