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What Lies Beneath: The Complex Web of Emergency Department Overcrowding : Emergency Medicine News


Emergency room overcrowding, health care

A poster (pictured) perches on my living room wall, showing its staggering complexity to anyone passing by. I don’t know why it takes pride of place on my wall when a stylish print would surely do better, but I like to remember the almost hallucinatory sophistication and connectedness of our biological cellular processes, even in such superficial rendering. This reinforces why trials of single interventions in medicine so often fail to show benefit; how do you separate a single stage in a tornado of interacting factors?

Another network of similar convoluted complexity in healthcare is large-scale. Every particle of it is also so interconnected and altered that little is done to change the organism as a whole. It’s a global phenomenon, and I thought this might be an opportunity to share some truths from below, where our emergency services suffer from the same scourge of crowding as others all over the planet.

The main reason our emergency departments are crowded is because emergency patients don’t have to be there. People presenting to the ER in a perfect world would have a short episode of care and then be discharged or taken to their hospital bed with clean, welcoming sheets. Heck, in a perfect world, we wouldn’t need emergency services at all, such would be the strength of preventative health strategies, chronic disease care and avoidance of risky health behaviors, things put in place so no one ends up needing our services in the first place.

But reality has denied us this ideal. The cause of our overpopulation, certainly in the land of the Antipodes, is as multifactorial as the stages of an inflammatory cascade. A myriad of overlapping pre-hospital, intra-departmental and post-hospital failings culminate in overcrowding, like a clumsy metaphor for kidney failure.

Once you start to identify the causal elements in society that lead to rush crowding and how they affect each other, you can’t stop. Most somehow reflect the crumbling fabric of society and, whatever their root cause, focus like a laser in the emergency department, where people end up when they have nowhere to go. Just to scratch the surface, in Australia we have a shrinking distribution of family doctors, with their remuneration undervalued and falling relative to the cost of living, serving less of our underrepresented and disenfranchised populations.

General practitioners are also less likely to visit nursing homes, which are filling up with an older and sicker population. Residents who experience unwitnessed falls in nursing homes find themselves in ambulances stacked outside our bulging ERs waiting to enter, all for lack of yet another safety in their own surroundings.

The web is growing

Health literacy in the community is deteriorating, with an antithetical and inversely proportional increase in health misinformation. Existential unhappiness also increases inexorably, perhaps with the big lie that we should all be happy. This has led to a pandemic of self-medication, trying to tone down the horrors, not to mention the deep psychological wounds of the real pandemic. Where I come from, Perth, the river is flowing with alcohol and crystal meth. Ambulances remain crawled outside all metropolitan EDs, unable to unload the tide; there is no room in any of the inns in town.

We are suffering from a constantly shrinking supply of beds on the other side of the kidney and emergency department. Hospital beds are extremely expensive, so restricting them is an obvious way to keep the voracious beast of healthcare spending at bay. We have a socialized version of medicine in Australia. I understand that socialized medicine is a little too much on the nose for many Americans, and that it has good and bad aspects (one of the most poignant being that no one here is ever bankrupted by the care of health), but this means that the beds at the back-end of the ED are precious and insufficient in number. When they are not available, the traffic jam manifests itself in the emergency room: blocking access to the signal and boarding of hospitalized patients. The few hospital beds are filled with people with nowhere to go from there, again the endpoint of a thousand slingshots and arrows of an imperfect society.

Of course, our emergency services have their own inefficiencies, all magnified by overcrowding. Everything is harder to do when patients are crowded in the hallways, loved ones knock on windows, ambulances come out the front, medical and nursing staff wither with the neglect common to all these overwhelmed systems, sick calls are on the rise, rosters aren’t being filled and burnout is raging like wildfire. . Perhaps the most serious example of all is that of the aisles of institutionalized psychiatric patients. We detain these patients in the most inhumane conditions, forcing them to wait days for a decent bed, no doubt aggravating their illnesses.

I wanted to make an elegant diagram, like the one that adorns my wall, of how all these societal failings connect like a glorious web, with influence and feedback loops and domino effect power, but that wouldn’t be not so delicious.

Solutions are not easy to find, and money thrown at one aspect at the expense of another can barely move the needle. We used to say that overcrowding was an entirely hospital problem, but perhaps it’s better to describe it as an entirely societal problem instead.

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Dr Johnstonis a certified ER doctor, so the same as you but with a weird accent. She works at a trauma center in the old fashioned end of Perth, Western Australia. She is the author of the novel dust fall, available on his website, She is also a regular contributor to the Life in the Fast Lane blog at Follow her on Twitter@Eleytheriusand read its past columns at