Clogged hospital arteries

By Warren Gamble*

Brent Gamble started feeling unwell at work last Tuesday. At first he thought a dodgy hash brown at breakfast was to blame for the sudden nausea. But as the day wore on it was joined by a dull headache and shortness of breath. At home that night he developed a fever and could not lie still because of aching muscles.

At 8pm his wife, Trudie, who had read about the symptoms of meningitis in newspaper coverage of the deaths of a Waiouru soldier and a Wellington woman, asked if he had a sore neck. When he said yes, they set off from their Glen Eden home to Auckland Hospital.

"He had neck pain, aches and flu-like symptoms and I wasn't going to take the risk," Trudie says. "I mean, you die from this thing."

Meningitis attacks the lining of the brain and the spinal cord, and can kill quickly if left untreated. It is notoriously difficult to diagnose, particularly in its early stages because many of its symptoms resemble the flu.

The Gambles arrived at the hospital's crowded emergency department at 8.30pm. Brent was assessed, put on a trolley and joined half a dozen others in the corridor of the overflowing department on one of its busiest nights. Next to him was an elderly woman with bruising, possibly from a fall, a woman with a diabetes condition and others with respiratory illnesses.

"It was like a traffic jam," he says.

After initial tests to rule out heart problems, he spent about two hours - others had to wait up to seven hours - in the hall, before being taken to a cubicle where a doctor performed more tests and took his history. He did not have a rash, but the non-specific origin of his fever and his headache and sore neck were of enough concern that medical staff recommended he stay for more tests, including a lumbar puncture. It removes spinal fluid which provides the most effective diagnosis of meningitis.

By 12.30am he was seen by another doctor who gave him the option of a course of antibiotics which would knock out any meningitis present. Faced with a choice between a large needle inserted in his back and a much smaller penicillin injection, he chose the latter.

Gamble still does not know if he had the disease but is finishing a course of penicillin in North Shore Hospital, where he was transferred because Auckland had no ward beds and his West Auckland address meant he was a North Shore patient. He eventually did have a lumbar puncture and is waiting for the results of new DNA tests which can pinpoint meningitis despite the doses of penicillin which mask the disease.

Brent Gamble is grateful for his relatively quick and "better safe than sorry" attention for what is likely to be something less serious, such as a severe viral infection.

Trudie Gamble, though, is angry at what she saw in the corridor on Tuesday night; the crowding, the waiting, the not knowing what was going on because staff were too busy to spend much time.

"There has to be a better way," she says.

The case highlights a recurring issue for hospitals already under strain with the annual winter workload, and faced with a potential disaster such as a bus crash or disease outbreak.

How long can they run at or beyond capacity without patients suffering or even dying?

Investigations into the meningitis death of 25-year-old Wellington woman Nileema Sharan will look at whether Wellington Hospital staff could have responded differently as she waited for more than three hours without seeing a doctor. Her family said she complained of a splitting headache, had a rash on her neck (a meningitis symptom) and a temperature.

She was then taken to a nearby accident centre where a doctor gave her painkillers and sent her home, where she died the next morning.

Prime Minister Helen Clark said this week: "Personally I'm quite shocked that someone can sit for three hours in the emergency department and not have anyone notice that they had signs of meningitis.

"I would have thought there is a lot more meningitis awareness around these days, and my heart goes out to the family."

This week many of the country's hospitals have been full as winter kicked in. In Auckland the three main hospitals have been overflowing. On the busiest days in the past fortnight some patients have been waiting up to nine hours at Middlemore, seven hours at Auckland, and also had long delays at North Shore, largely because of an increasing winter workload.

And in central Auckland, at least, the raised awareness of meningitis has added to that workload and the delays. On Tuesday Gamble was one of five people who turned up at the emergency department or were referred by their GPs with potential meningitis symptoms.

The hospital said some patients were being referred as a precautionary measure with symptoms which did not match meningitis. The heightened awareness which got them to the hospital also meant they were seen relatively promptly, and some required isolation. The ripple effect of that is fewer beds and extended delays for other patients, up from the "normal" two hours to more than seven hours on occasions this week.

In a notice to GPs - possibly with the Wellington case at the forefront - the Auckland board asked that patients be prepared for the delays "so they know what to expect but will have confidence to speak up should their condition worsen rapidly while waiting".

Auckland Hospital's clinical director of emergency medicine, Peter Freeman, says it is natural for GPs and walk-in patients to be more cautious when meningitis deaths are highlighted.

"To some extent that is better," he says. "We would rather be busy and not miss anyone with meningitis."

But how busy can an emergency department get before the misses start happening?

International literature says hospitals should run at 85 per cent capacity to operate efficiently and cope with peaks. Freeman says the Auckland emergency department operates at 95 per cent all the time, with peaks pushing it well over 100 per cent.

Over the past year there have been sick people in the emergency department corridor almost daily - nine bed spaces in the hall are assigned a number so patients can be tracked.

Freeman says the emergency department in the new city hospital opening in October will have double the beds, at 50, as well as an adjoining 45-bed admission and planning unit which would provide invaluable space for patients needing short-term assessment, particularly in peak times.

A large part of the existing problem is the lack of beds in Auckland Hospital wards, leaving a growing backlog in the emergency department which was designed only to provide initial assessment and treatment.

Some doctors argue that the new hospital, with fewer beds than the combined numbers at Auckland, Green Lane and National Women's, will mean the emergency department problem will remain or even worsen.

But hospital managers say the new admission unit and shorter hospital stays will create a marked improvement.

The Auckland District Health Board acting chief medical officer, Dr David Knight, says the recent events show how well public hospitals can cope despite incredibly high peak workloads and without all the resources they would like.

What worries Freeman is a close-to-home example of a larger, nearly new emergency department faced with overloading only two years after its opening.

Middlemore Hospital's 96-bed department was designed for an average of 190 patients a day. With an earlier and much more severe winter peak than expected, it is now seeing up to 280 a day. This week some patients had to wait up to nine hours for treatment, the 16 corridor beds were full and up to 20 more were in the waiting room.

The services manager, acute care, Dot McKeen, says the spike began a month ago, with a large increase in influenza-like illness. It put staff under increasing pressure, with many being called in from home after finishing their 12-hour shifts. The overcrowding meant, for example, that some patients whose conditions appeared stable but had the potential to worsen were not seen as regularly.

"It's just a matter of keeping going really," McKeen says. "You do the best you can at the time."

No one, she says, would ever want a situation like the Wellington case. "I would have a lot of empathy for their staff, because I am quite sure they did their best also."

Herald Feature: Hospitals under stress


* Warren Gamble was writing about his brother's experience in a crowded Auckland Hospital hallway