Before starting in the emergency department at Hamilton, I had the expectation of being thrown into a chaotic, busy environment with patients bleeding, screaming, and flat-lining throughout the day. (I know, I watch too many Netflix shows.) In reality, I was surprised at how calm the days were compared to my expectations although there could be quite a lot of random screaming from time to time.
Comparing Workloads: Hamilton vs. Sweden
I will be comparing this experience with my time working in the Lund emergency department back home in Sweden. It's important to note that this comparison won't be 100% accurate, as I work as an assistant nurse in Sweden, not a registered nurse. We'll dive deeper into these differences later, but for now, I'll just say that I miss the workload we had in Sweden. The people who thrive in emergency departments around the world are likely a little bit crazy and adrenaline seekers—at least, most of us prefer a busy day.
Understanding the Structure: St. Joe's Emergency Department
At St. Joe's, the Emergency Department (ED) is divided into several distinct areas:
AIM (Ambulatory Inpatient Medicine):Â This is where walk-in patients, who are typically not very critical, usually end up.
The Clinic:Â This area is designated for patients who are not critical but require a lot of personal assistance, such as help with changing diapers, eating, or going to the bathroom.
The Island:Â Ambulance patients who are not critical are directed here.
Acute Rooms:Â These are reserved for the more critical patients.
During the day, there are also two nurses assigned to Orders, which is the area patients are sent to after triage to get their blood-work done. From there, they are usually sent to AIM.
The Team: Nurses, Externs, and Physicians
The professions working in the ED include registered nurses (RN), registered practical nurses (RPN), externs (nursing students), physicians, and their interns (medical students). The ratio of nurses to physicians is still somewhat unclear to me, but I would estimate that there might be one physician for about every 10 nurses. This means there are a lot of nurses and not so many physicians.
Each nurse is assigned to specific rooms if they are working in the Clinic, Island, or Acute, or to specific patients if they are in AIM. The maximum number of patients each nurse is responsible for is typically four. When covering for a colleague during a break, this number can rise to eight patients for the 30-45 minutes that the colleague is away. Nurses help each other when needed, but it can become very isolated and demanding when you are solely responsible for a patient.
The Progression Path: From AIM to Acute Care
New nurses at St. Joe's start in AIM and gradually work their way up to the Acute care beds. This allows them to build experience and confidence before taking on more critical cases. However, I feel that since there are so many more nurses compared to doctors, many of the nurses have to wait for the physicians to come up with a plan in order for things to move on. With fewer physicians, this process takes time, and the nurses often find themselves waiting for a plan to be made, which can make it seem to an untrained eye that there is a lot of staff who aren't working, when in reality, they are simply waiting for the necessary medical decisions to be made
A Comparison to Lund's University Hospital in Sweden
At Lund's Hospital in Sweden, the Emergency Department is structured differently, with four distinct teams (and I honestly don't know what happened to team 3):
Team 1: Generally handles patients that need more assistance.
Team 2: Deals with the more critical patients.
Team 4: Focuses on orthopedic patients.
Team 5: Manages the less acute and more ambulatory patients.
All rooms have the ability to monitor patients, and except for Team 5, all rooms are single occupancy. Patients can come from either walk-ins or ambulances, and triage sends them to the team that has fewer patients, matching the team’s specialty as closely as possible.
We have nurses that are assigned acute care phones on every shift. If there is a level 1 call that requires acute care, there are three specialized beds for those patients. When paramedics call in on the radio with a level 1 patient, the nurses leave their teams or other assignments to meet the ambulance that take the patient directly into the Emergency Room.
Acute Care: Daily Assignments and Meetings
In addition, we have a morning meeting and a night shift meeting with the head nurse, who informs us about how the previous shift has been, how many patients we have, and if there is anything else we need to be aware of. At 9 am, everyone working in the emergency department gathers at Team 2 for a 5-10 minute briefing on staffing status, any special agendas and to wish us a good day.
There’s always one nurse and one physician in charge, with their offices located in the middle of the emergency department. Some of the acute team nurses can sometimes be floaters. Most of the time, we have an ambulance triage, where ambulances come to a room with five beds to drop off their patients, give a report, and head back out. If we are understaffed, the ambulance nurse signs the patient into a computer and decides themselves which team to go to. This is a significant difference from Hamilton, where paramedics are not allowed to leave the hospital until a nurse has been assigned to the patient. This can sometimes take a long time because of logistics, causing a delay in paramedic services as they wait in the hospital hallways with their patients.
In Lund, each team typically consists of one registered nurse and two assistant nurses, managing on average between 7-15 patients. We also have assigned physicians and interns to each team. The nurse works very closely with the assistant nurses, and we have constant briefings about patient statuses and what they are waiting for throughout the day. The assistant nurses, being two in each team, usually get the closest contact and spend more time with the patients, which helps them develop critical skills that suit the emergency environment and ensure patient safety.
The work is fast-paced because spending 15 minutes with one patient can result in another being sent off and two new ones assigned so the constant team briefings are a key to success and patient safety. In the middle of the day, the evening shift arrives, and two teams work together to cover each other's breaks. We work three shifts in Sweden, compared to the 12-hour shifts in Canada. I do like the 12-hour shifts, and I’m going to miss them, but working in Canada makes me miss the integrated teamwork that the emergency department in Sweden is all about, where all staff work together holistically to keep everything moving. I feel that it is more integrated, more fast-paced, and more patient-focused in Sweden.
Patient Clientele: A Tale of Two Countries
When it comes to the types of medical cases we see, the emergency in Canada don't seem that different from Sweden. We both deal with a wide range of conditions such as meningitis, endometriosis, fetal demise, ascites, heatstroke, broken bones, heart failures, esophageal varices, not the mention the numerous ways our stomachs can fall ill. The same scenarios unfold in both countries, reflecting the universal nature of health crises. Not to forget to mention the ring that needed to be cut off to save a finger.
However, where St. Joe’s truly stands out is in its overdose rates. I worked a shift the day after payday, and during that one shift alone, we had around 8 overdose cases. All of these patients came in breathing, thanks to the paramedics doing their job well, and our role was mainly to observe them to ensure they were stable. We’d give them something to eat, maybe some new clothes, and then they’d head back out of the hospital. It’s a vicious circle that seems to have no end in sight.
Furthermore I've never before encountered as much forced care as I have in Hamilton. We cared for quite a few patients being tied to their beds under police/security surveillance because they are either a threat to themselves or others. One patient almost managed to bite me while we were trying to hold him still to get some bloodwork. It's unfortunate and heartbreaking, as these souls come from all walks of life—many of them Canadian born, highlighting the link between homelessness and addiction, and the immense difficulty in breaking free from it.
I see the trend in Sweden moving in the same direction, with more and more homeless people in the bigger cities, many of whom also struggle with drug addiction. It’s a sobering reminder of the global nature of these issues and the challenges we face in addressing them effectively.
A Call to Action: Making a Difference
Witnessing the struggles of patients dealing with various challenges, including addiction and homelessness, has ignited in me a deep desire to make a more substantial difference. My journey into nursing was driven by a sense of unfulfillment in my role as a part-time firefighter, where I felt I wasn't making enough of an impact on people’s lives. The urgency and gravity of the situations I encounter daily in the emergency department have only strengthened my urge to find effective solutions to address broader social issues and improve lives.
If anyone has ideas, suggestions, or solutions on how we can tackle these complex issues and help people find good paths forward, please reach out. Let’s brainstorm and collaborate to make meaningful changes. Together, we can work towards creating a healthier, more supportive environment for our fellow human beings.
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