“Exhausted” doctors, nurses, technicians and assistants, many with burnouts. 12-hour and even 24-hour “demanding” shifts. Overcrowded emergency rooms. Patients waiting for eight, 10, 12 hours. There are thousands of lives in the hands of teams that want to “give more and can’t”. Portugal had, in the last six months, the largest number of patients ever in the emergency room.
“2019 had already been the year with the most episodes since we have a record. But since June of this year, every month, we have had more episodes of urgency than what we had in 2019″, said, in an interview to SIC Notícias, Nelson Pereira, physician and director of the UAG Urgency and Intensive Care Medicine at Hospital de São João, in Porto.
Near six million people resorted to the emergency service in 2019. In the last six months, there was another 5% turnout. Numbers vary by country. However, between 35% and 50% of patients who go to the emergency room did not need to go. These patients had, for example, blue bracelet (not urgent) or green bracelet (not urgent) Manchester Triage, the method of establishing patient priority.
According to the National Health Service, only in October there were 534,001 emergency room visits in Portuguese hospitals. It was the month with the highest attendance to the emergency room. In mainland Portugal, the region of Lisbon was the one with the highest number of calls (190,829), followed by the North (189,250), the Center (93,349), the Algarve (30,528) and the Alentejo (30,045).
The doctor at the Hospital de São João said that, at this time, is not admitting more patients than admitted in 2019, which means that “what is increasing is the number of patients with non-urgent episodes, which they shouldn’t go to the emergency room.”
“This means a charge for the services. It harms the treatment of patients who have urgent situations, it causes a brutal wear of health professionals, who are in a difficult situation either from a personal point of view, in terms of ‘Burnout’, or from the point of view of the organization of the service”, explained the doctor.
Carla Araújo, an internist at Hospital Beatriz Ângelo, in Loures, recognizes: “We are all tired. The turnout is high, the shifts are complicated. Imagine a 12-hour or even 24-hour shift in the emergency department. The demand is too great. I like it a lot, it challenges me a lot, but the overload is great and the physical demand is high”.
“We have the lives of our patients in our hands. We always feel that we should be more and we are not”, vents.
“What burdens us it is not taking a patient with a heart attack and treating him. It is to receive a patient with back pain for two months and has not yet been to the doctor. What tires us is to receive an unacceptable volume of people composed, in large part, of patients who should not go to the emergency room”, stresses the UAG director of Urgency and Intensive Medicine at Hospital de São João.
When should you go to the emergency room?
It is not always easy to see whether, in the face of a given symptom, the person should or should not go to the emergency room. However, there are situations that leave no doubt.
As people must go to the emergency room when life is at risk or when they have “a situation serious enough that it puts some of your organs at risk”, explains Nelson Pereira.
The head of the Hospital de São João mentions “situations that no one has doubts about”: a significant trauma, when there was a road accident, one broken leg, when there is a bleeding wound, shortness of breath, muscle strength deficit, mouth to the side, difficulty speaking, severe pain in the chest and left arm, accompanied, for example, by nausea and cold sweats.
The internist at Hospital Beatriz Ângelo recalls, for example, “sudden neurological signs”, extreme tiredness, fever and malaise for three days.
In these urgent cases, the people should call 112, “instead of getting into their own car on their way to the hospital”, stresses the doctor.
“Often, the nearest hospital is not the best one for treatment. Patients can benefit from sending a medical team for earlier help.”
When should you not go to the emergency room?
As trips to the emergency room happen “very often”. When there are doubts about what is happening, the patient must contact an entity capable of helping to understand whether it is an urgent situation or not. It is the case of the family doctors, during the day and during the week, and the SNS line 24, at any time of day.
“No one should go on their own initiative, on their own foot, to an emergency room”, says the doctor Nelson Pereira.
Asked about symptoms that do not justify an emergency visit, internist Carla Araújo exemplifies: indisposition, so-called “runny nose”, recent sore throat with no signs of respiratory distress and ingrown nails.
The doctor at the Hospital de São João adds that the fever without symptoms, a simple urinary tract infection, “knee pain for a week or back pain for three months” neither do they justify a trip to the emergency room.
“This type of situation has a place to be dealt with, that is not the emergency room. In principle, it will be in primary care. Nobody takes away the idea that people are worried and need a referral and clinical guidance. But it has to be done in the right place and at the right time”, says the UAG director of Urgency and Intensive Medicine at Hospital de São João.
“It may be the most obvious and fastest path, but it’s not the best from an organizational point of view”
Both the physician Nelson Pereira and Carla Araújo, internist, recognize that the people got used to going to the emergency room because “they think it’s the right way”.
“It may seem the simplest, the most obvious and the fastest, but it’s clearly not the best from an organizational standpoint,” says Nelson Pereira.
According to the same doctor, São João, in Porto, is the country’s hospital that receives the most patients in emergencies. On average, there are 550 adults a day, but the ideal would be 380. However, the situation is getting worse:
“Per day, in the last month, in the three emergencies together – adults, pediatrics and gynecology/obstetrics -, we walk around 780 to 800 patients a day. On the worst days, we even surpassed 900“.
“People get very tired, they can’t recover from one shift to the next, even from a mental point of view”, says the person responsible.
According to physician Carla Araújo, the problem of surging above responsiveness is “quite complex”. The urgency model has been discussed for many years, he says.
“Portugal is Europe’s champion in the search for emergency services for all types of care, whether it is a serious, acute complaint that puts the person’s life at risk or low back pain that has lasted several months. This access to healthcare needs to be reorganized”, defends the internist.
The doctor appeals to creating alternative gateways, as rapid diagnosis units, in the case of chronic diseases:
“Portugal is a very aged country, our patients are complex. Many must have four, five, six chronic diseases at the same time that sometimes decompensate and resort to the emergency department.”
“If a person doesn’t have a family doctor, doesn’t have access to consultations and has any symptoms that bother him, he will seek emergency care. By not improving the accessibility of healthcare, patients will continue to resort to the only gateway,” he says.
Creation of the emergency medicine specialty
In an interview to SIC Notícias, the director of the UAG for Urgency and Intensive Medicine at Hospital de São João highlights the importance of creation of the emergency medicine specialty “for the sustainability of the service in the coming years”:
“IT’S very difficult to recruit people for this task”.
Due to the difficulty in retaining professionals, most hospitals resort to service providers, says the expert, and adds:
“From the point of view of organization and management, it makes no sense to set up such an important service with people who are not from the hospital and who only come for a few hours when they have availability”.
“Without the creation of the specialty, there will certainly be many crises in the near future”, refers.
Is there pressure from patients with covid-19?
Asked about the pandemic, physician Nelson Pereira recognizes that there have been more patients in the respiratory area. However, he says that, for now, the Hospital de São João, in Porto, is not under pressure for admissions:
“The situation at the moment is calm from a covid point of view.”
Carla Araújo, a doctor at Hospital Beatriz Ângelo, stresses the successful vaccination against covid-19:
“The increase in daily cases shows that vaccination is a success. There are infected, but few have serious illness“.