By Dr Stephen Gourley, President of the Australasian College for Emergency Medicine
A torrent of verbal abuse, a shove, and then a punch. Close your eyes: are you at a Saturday night bar fight? Open them: no, you’re not, you’re working a regular shift at an Emergency Department anywhere in Australia.
As ED physicians we devote our lives to providing health care for people experiencing urgent and life-threatening medical emergencies. Walk with us on a shift in the ED, where we must be a jack of all trades, ready to respond with skill and tact to people struggling through one of the worst days in their lives.
Enter the first cubicle, and you meet a 14-year-old looking the worse for wear after a bone-crunching tackle. Moments later, you’re rushing to the next bed, where a recent retiree’s chest pains are being treated as a possible heart attack. Next door lies a feverish baby with a blotchy rash, whose frantic parents fear meningitis. As you hurry to your next admission, you pass a cubicle where a man lies behind a thin curtain as police officers hover nearby for him to wake.
Out in the waiting room sits a man with his arm around his elderly mother propped up in a wheelchair. She is dizzy and disoriented after a fall and may never be able to live in her own home again. Across from them, a mother who was unable to get a GP appointment and has run out of urgently needed medication doles out snacks and drinks to her children. The children weave their way around walking frames, wheelchairs and the wounded, witnesses to the pain on display.
In the triage queue, which extends to the entrance door, a girl who has been bitten by a dog sobs loudly as her boyfriend holds her up. A middle-aged man still in his gardening clothes holds a homemade bandage to his eye. A woman in a dressing gown lies down in the foetal position clutching a half-full plastic sick bag while her partner holds her position in the line.
You never know who’s next to come through the waiting room or off the ambulance stretcher. But we pride ourselves on treating anyone who comes through the door. It’s a big part of what makes the job so rewarding. But lately, those doors hardly have time to swing shut. More and more people are requiring our services, to the point where our whole health system has become completely overwhelmed.
In 2023-24 over 9 million people attended public EDs across Australia – the highest number of presentations ever recorded. Unfortunately, hospital funding, workforce recruitment, bulk-billing incentives, aged care services and NDIS support haven’t kept up with this trend. More patients, fewer doctors and longer waiting times are always going to lead to more frustration.
Fuller hospitals mean ED patients who need to be admitted to hospital must wait in the ED. There are no beds available for treating new patients who arrive in ED.
I’ve heard it said that while hospital wards have fixed walls, the ED has elastic walls which are expected to endlessly expand. However, we've reached the point now that our hospitals are bursting at the seams, with this most visible in the ED and down the ambulance ramp.
What does ‘overwhelmed’ look like? Well, it means that rather than treating the recent retiree in the relative privacy of an ED cubicle, you’re doing so on a stretcher lined up in a corridor. It means that the elderly mother waits in a ramped ambulance for hours. The parents of the sick child are still in the waiting room … you desperately want to help them all, but there’s just not enough beds in the hospital, not enough staff to care for people safely and not enough supports in the community to reduce the system’s reliance on EDs in the first place.
Most people understand that the sickest patients are prioritised. That acute cases are seen first, as they should be. But after three, five, seven hours, patience can wear out. People angrily approach nurses demanding to know when their loved one will be seen; they confront doctors for calling the names of other patients who arrived later than they did, asking how much longer will they be expected to wait? But there is no quick answer to that question and so the damaging end result can too often be outbursts of violence.
This is incredibly heartbreaking. It's disheartening to see a system that you know can work so well be overwhelmed to the point where it's totally dysfunctional. And it’s become so frightening that this situation has been leading to so much violence and aggression in the ED.
Distressingly, we're seeing really serious incidents against frontline ED staff.
A violent incident can lead to staff leaving the profession and the ensuing shockwaves can affect the whole ED. Some victims are too frightened to return to work. It takes a big investment, a long time and great dedication for anyone choosing a career in emergency medicine. When staff leave after a violent incident it is not only devastating to the person involved, but also to your team and the whole system.
To be honest I'd feel pretty angry, frustrated and a bit mouthy if I had to wait eight hours to be seen in an ED. But while frustration is understandable, attacking people who are just trying to help is not okay under any circumstances.
As ED physicians, we are doing all we can to deliver the best care under trying circumstances. We’re also working with others across the health system on solutions to this wave of violence, but they are not simple, and do not lie solely in the ED.
The Australasian College for Emergency Medicine (ACEM) recently released the Breaking Point: An Urgent Call to Action on ED Safety report and published findings from the study Enough is enough: Alcohol-related occupational violence and aggression in emergency departments in Australia and New Zealand, which revealed the alarming levels of violence and aggression faced every day by Australia’s emergency medicine workforce. Recommendations specific to Federal, State/Territory health authorities as well as hospitals were provided to address this significant problem and our hope to continue this much-needed national conversation.
Right now, with an election in the offing, we have a chance to create a better, fairer, safer health system. All of us – politicians, patients, and the general public alike - must work together to achieve this.
In addition, we must make sure that every part of our health system, including ED, has adequate staffing and capacity to ensure the system can function effectively as a whole.
Fixing our healthcare system will be hard, but we must not leave it in the too-hard basket.
It’s time to start healing the damage to our health system and fixing our EDs once and for all. But we must start now.