Jack Webb had had enough.
He’d languished for six hours in a chilly emergency-room hallway, had a broken IV in his arm, and was bumped from his room by another dying patient during five days of struggles in Halifax’s largest hospital.
On his last day, he heard staff yell the clincher: “If he stops breathing, don’t resuscitate.”
Not long after, the retired businessman turned to his wife and made slicing motions on his Halifax Infirmary identity band.
“He said, ‘Cut it! … Cut it!”‘ recalled Kim D’Arcy, who sat by the 68-year-old’s bedside as he fell into despair.
“I believe Jack was terrified. … He wanted to go home.”
Webb died hours later on Feb. 1, after receiving care that Dr. Alan Drummond, a spokesman for the Canadian Association of Emergency Physicians, says is an example of “the distinct level of human suffering associated with crowded emergency departments and crowded hospitals” plaguing Canadian medicare.
Canadian emergency rooms are increasingly issuing special “codes” indicating they’re too full – a process that sets off a domino effect where gravely ill people like Webb are pushed into regular hospital units already operating beyond capacity.
D’Arcy says her husband had multiple sclerosis, but was a “fighter” and carried on a vigorous and active life as a walker, canoeist and world traveller. He was also a regular volunteer patient, offering himself for interviews with student doctors.
The life of Jack Webb
Born in Wolfville, N.S., Webb was the former owner of a Mad Man McKay home electronics franchise.
On Jan. 12, he was told by a doctor at the Queen Elizabeth II Health Sciences Centre that he had pancreatic cancer, and it had spread into his adrenal glands and liver.
The diagnosing doctor discharged Webb to his suburban Bedford, N.S., home, yet D’Arcy says she doesn’t recall receiving detailed instructions on diet, palliative care options or medication for her critically ill husband, and said she was uncertain of what to expect.
In a single week, Webb declined so quickly he lost the ability to manage his medications for cancer and his multiple sclerosis. On Jan. 27, he was struggling to breathe, prompting a rapid return to the Cobequid emergency room, the suburban facility where he was first diagnosed. Webb was transferred to the Halifax Infirmary’s downtown emergency department.
Later, she said she learned Webb should have been seen by a specialist from the hospital upon arrival, according to a patient complaints adviser she later contacted.
Instead, as the clock ticked past midnight, Webb lay on a gurney shivering in an ER hallway, as other patients rapidly filled a lineup around him.
“We felt like screaming. We felt very sad, very frustrated, helpless,” recalled D’Arcy. “When an ER doctor saw Jack at about 7 a.m., he told us that Jack was the sickest man to arrive into emergency that night.”
D’Arcy, a senior property manager who has worked in quality assurance, found herself growing confused, exhausted and disoriented by the chaotic atmosphere.
What she didn’t realize was the ward had repeatedly been going through a process called “code census,” an overcrowding protocol that spills excess patients into the main hospital’s hallways, sets off bed bumping and is a wider sign of a hospital beyond its capacity.
Overcrowded and over capacity
The overcapacity code – used widely across Canada under various names – allows a hospital emergency room to declare an “unsafe” situation and start shipping out patients to other floors.
The Nova Scotia Government and General Employees Union brought the protocol to public prominence last month, releasing data showing that what was supposed to be an occasional measure to deal with ER overcrowding had become a regular event through the winter months at Halifax hospitals in the Nova Scotia Health Authority.
In the Halifax Infirmary, the code was called 23 out of 31 days in January, including the days when Webb was there.
The data also provided a portrait of a hospital caught in a winter-time pressure cooker. Its ER was receiving the highest rate of patient visits – at times surging to about 250 patients per day – in over two years. Overall, the average number of patients showing up daily at emergency had gone up by about a quarter in eight years, from 161 to 204.
Dr. David Petrie, the co-lead of an emergency program planning committee at the health authority, said in an interview that his hospital is facing a problem common in Canadian medicine – the reaching of capacity in terms of acute care beds.
“In order to work in a system like this you need 15 per cent search capacity. Your average day your occupancy should be 85 per cent (in the hospitals). We run our hospitals across the country at 90 per cent and sometimes at 100 per cent,” he said during an interview.
The hospital’s goal is to see seriously ill patients within an hour to an hour-and-a-half, he said.
“Seven hours in an ambulance hallway, we try to avoid that as often as possible. That’s where we struggle with our surge capacity … That, any of us would agree, is not reasonable,” said Petrie.
D’Arcy said as they moved from the hallway into the ER, she continued to see a facility struggling to cope.
When Webb was admitted to an emergency room, D’Arcy noticed that after three hours his intravenous wasn’t dripping. “She (the nurse) told me they had run out of pumps for the IVs,” recalled D’Arcy. It was fixed shortly after the problem was noticed.
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A short lived period of hope
The next day, Jan. 29, things briefly looked better for Webb, when he was shifted from ER to a private room with a telephone and television.
But it was a short-lived period of hope.
On Jan. 30, as code census protocols kept ER patients flowing through the hospital, he was informed another patient who was dying needed his space. He was shifted to a teaching unit room shared by three other patients, one whom had a viral infection sign posted on their curtain.
“He was placed in a corner far away from the nurses’ station. This was concerning, as Jack was bedridden and his mind confused … which meant if he got into distress he may not have the ability to ring for help,” said D’Arcy.
On Jan. 31, Webb was unable to lift his food tray or consume solid food, but he was booked for a scope procedure that D’Arcy thinks was pointless due to his weakened state.
She said after it was complete, one of the attendants in the recovery room yelled over to a paramedic.
“They said, ‘By the way if he stops breathing, don’t resuscitate!’ Unfortunately, Jack heard that, he was awake enough to hear that. I heard it, my sister heard it. We were very hurt he heard that,” she said.
That night, she witnessed her husband making the slashing motions at his wrist and “trying to pull off his IV.”
She is still awaiting details of how he died a few hours later, but worries he wasn’t able to signal a nurse.
Distressed by her husband’s experience, D’Arcy said she launched a public complaint process, but after several telephone conversations concluded it was pointless to pursue the matter and agreed to close her case.
“The Queen Elizabeth II health care system is broken and puts patients at risk,” said the 51-year-old.
Brian Butt, the patient services manager with the Nova Scotia Health Authority, said he can’t speak to an individual patient’s case, but said in general it is not standard practice to shout do-not-resuscitate orders in cases like the one described.
Even gravely ill patients can be moved to make way for other dying patients, said Butt.
Petrie said Webb’s case is nonetheless the type that “keeps us up at night.”
“We need to move patients around as creatively as we can to create spots to allow patients to come in. To reduce that seven-hour offload time we have to do things upstairs (in the hospital), so there’s a constant tradeoff and that creates this tension. Health care workers are trying to do their best for the patient in front of them at the time,” he said.
Attempting to fix the problem
Butt says the hospital is doing a review of the use of acute beds in internal medicine and in the Victoria General hospital, an older facility that is part of the same central zone of the Nova Scotia Health Authority as the Infirmary.
He said after those reviews, it’s possible the authority will officially state, “we need additional beds in the system.”
However, Drummond – who has been commenting on crowding issues for over a decade – said the reality is that hospitals are already operating too close to the edge, both in Nova Scotia and across the country.
The calling of over-capacity protocols like code census simply is a symptom of the problems, he adds.
“Where’s the value of an over-capacity protocol if you’re continually in an over-capacity protocol? Doesn’t that say something about hospital capacity?” he says.
Meanwhile, for D’Arcy, the questions remain, disturbing her sleep and her grief.
Why didn’t somebody provide her with clear information about her husband’s diagnosis earlier? Why did her husband lie in a hallway without seeing a doctor? Why was he bumped from a room where his death might have been more peaceful? Why the shouted comments about his resuscitation?
“It was hard,” she says, weeping after requiring almost four minutes to list off her list of issues.
“When you’re there, every day, you could see the deficiencies.”