Dyshopia mathematica

The Crumbling Fabric of Society Gets a Scorecard

It’s no secret that emergency departments all over the planet are collapsing, buckling over like weary gravity into an event horizon*.

Or maybe it is. A secret. Maybe that’s part of the problem – that the bitter end, the heat death** we are approaching is only visible and comprehensible to us chumps turning up to work, shift after shift, inside those departments.

To be fair, the complexity of what ails us is not easy to get one’s head around. It’s no surprise the public and, ahem, politicians in charge can’t see why we are currently as overstuffed, unsafe and unsavoury as a Coles home-brand sausage that has split its mucosal casing in the pan and is spitting out hydrogenated effluent where it will***.

Complexity needs maths.  Maths needs someone who knows what they are talking about to translate the concepts to the readers. That person is not me. Instead, I shall rate the current state of emergency medicine, then see how it adds up when I am done.

The base problem here, of course, is overcrowding. But that is the end result of a thousand blossoms withering. The final failure of a panoply of variables, all of which have somewhere in their foundering heart the crumbling fabric of society, and all of which are interconnected. Let us count the ways. Let us rank them, in no particular order, giving them a score.

Access Block: 7 points

Haha. You thought it should have more. But access block is unfairly maligned, an innocent bystander, semantic collateral. It is little more than metaphor itself, standing in for something else. It’s a symptom, not a cause, but I am awarding it points anyway, because it is a KPI, and any sort of KPI gives me hives.

Not enough beds: 0 points

Now I’m being sneaky. Of course there are not enough hospital beds. But it is the WHY of the hospital bed lack that deserves all the credit here. Population increase: 15 points. (self-evident. Even I can work out the math that if the population increases and the bed-stock goes down, there is a numbers problem). Ageing population: 42 points (of itself should not be an issue but combined with the rest of the variables in the matrix, it becomes a force to be reckoned with). Our hospitals are full of patients with nowhere to go. They are cruise liners with execrable food that cannot disembark their passengers. The hordes have nowhere to go because:

Fragmenting extended family/home care: 22 points. Society no longer supports the concept of multi-generational care. So where can these ageing/complex needs patients decant to once they have no more need of a tertiary hospital bed?

Oh yes. Limited nursing home/aged care bed availability: 43 points. (See the pachyderm pacing below.) It is, however, unfair to direct our ire at simply the inadequate number of physical downstream beds. Where are the people to staff those beds, and care for the grey avalanche? Yes – why don’t people want to work in an undervalued, undertrained, unsupported and casualised role? Hmm. Got me beat.

Reduction in remuneration for general practitioners and primary care physicians: 85 points. Again, see below. Oh damnit, I just need to name it. The state-federal funding divide. It’s a major issue. Federal government pays for GP’s and aged care, state for hospitals. We have a classic case of ‘not my problem’ and let’s make this as unwieldy as we possibly can – bamboozle people with a labyrinth of monetary bureaucracy until everybody gives up and goes home.

OK The State-Federal funding divide: 473 points. Like a rabbit-proof fence**** but without the benefit of stopping a disease. Additionally, if people must pay for a GP because primary care physicians are not appropriately remunerated, but ED’s are free, it does not take Newton to figure out the consequences.

And a random scattering of other reasons for ED overcrowding, like flak:

The big lie that we are all supposed to be happy all the time: 80 points. Methamphetamines and alcohol might briefly soothe the grimness of reality, but it does bring in work, rot the teeth, destroy families, incite hideous and unforgivable violence and take up a huge volume of resource in the emergency department that would be better spent drinking tea and discussing the latest House of the Dragons episode.

Poor health literacy: 57 points. I would like to blame Mark Zuckerberg and Elon Musk for this. So I will. It is their fault. Mostly. It is not so much that the public don’t understand illness and disease, it is that they are fed an algorithm that is so full of bullshit in the service of clicks to make money for the unprincipled few that true information is harder to find in the waking screen-life of the world than happiness. Yes. I am cross. I could give late-stage capitalism a billion points here but I feel that would be cheating.

The thorny question – is modern medicine too expensive? 8 points. Who knows. Now we are in philosophical fiend country, the land of how care can be rationed when resources are, and must be, limited. Who gets to decide who gets the million-dollar chemotherapy to save one precious life, or how much medical intervention we should bestow on our venerated elders? Although an indirect variable, if we pay Paul, we must have robbed Peter. And from the same songsheet, should we be investing far more of the limited dollar into regional healthcare and education, the poorer areas, the underbelly, the disenfranchised, the marginal, to avoid them needing to come to the ED? And who should be making the decisions? (hint, not the short-term pork barrellers, but the public. And us.)

And from the final buffet, mostly picked over, a smattering:

Lack of seven-day hospital services: 28 points. How else do patients get safely discharged over a weekend?

COVID: 145 points. You bastard. Not only did it break morale during its first murderous round, now it is here to stay it continues to rob the roster of staff and increase the number of high-complexity respiratory patients stuck in the department with nowhere to go. Even yours truly can figure out this equation.

Staff burnout and moral injury: I have to be honest – I have no idea how to score this one. Let’s give it a century, a round 100 points. Burnout is both cause of overcrowding – the smoking ruins of staff leave, go elsewhere, or have trouble turning up and functioning at the heroic level required, and result of ALL OF THE ABOVE. (Let us remember. The definition of moral injury is being prevented from taking the actions you know to be right. What else does overcrowding wield but a morally injurious broadsword).

Anyone who works in the system will a) know hundreds more of these accreting, attritional cuts that could take proud place on the scoreboard and b) know that each day is, somehow, incrementally worse than the day before.

But before I tally up the scores, a question. Do any of us really know what emergency departments are for, these groaning, over-full, sinking vessels? We know what they are currently needed for, as elements of our society disintegrate and the wealth-poverty divide yawns ever bigger, revealing the teeth of the monster. But what SHOULD they be doing? What care should emergency departments be providing? We never stopped to ask, we simply piled ever more work into their elastic walls. Sure, small gains are made, but to be honest, it all needs a big-ass rethink. And we clinicians need to be at the table when it happens. As do those directly affected. What we actually need from those in positions of power is the most powerful tool of all. Transparency. The courage to tell the truth of why emergency departments are perilously overcrowded. It’s the first step to finding solutions. And, all of these things have solutions.

No. I’ve changed my mind. No complex summations and comparators will be made. There shall be no winner. No single fragmenting thread in the fabric gets to stand on the podium spraying champagne. They are all inextricably bound. Like those in medicine. Chumps, turning up, day after day, to provide medical care. Courageous, magnificent chumps, all of you. Let us come to the table and speak truths with neither prejudice nor fear, so we can be empowered to make some sort of change.

*Yes. I know. This is a terrible simile. Event horizons are the boundaries of black holes, so gruesomely powerful that they suck in all manner of space, time, light, and good sense. It is not an event, nor does it have a horizon, but it made me smile, so you must in turn suck it up.

** Even worse. I am sorry. But how fascinating are the theories about the end of the universe. A heat death? The big freeze? The big crunch? The big rip? The big bounce? The big slurp (seriously)? Some days, I think it can’t come soon enough. And what fun it would be to watch.

***My final apology. I have now mixed my metaphors beyond redemption.

****My bad.