A 35-year-old man reels from pain after dental work. He can't sleep, feels lethargic and even codeine won't quell the pain. Should he stay up all night in agony and try to see his GP in the morning, or drive to hospital?
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We know health resources are stretched and emergency departments are for just that – emergencies, but daily in Australia, 18,000 people are turning up to 24-hour public hospital casualty departments for treatment. In waiting rooms you will find people using them as quasi-medical centres; others in a drunken or drugged stupor, people in trauma and on death's door, the chronically ill and the mentally ill.
The man with the toothache finally fronts up to the casualty department at a major hospital. Just as well. Doctors took one look inside his mouth and found a rampant infection that had spread to his heart. Before long he was in intensive care after having his aortic and mitral valves replaced.
More people are turning up to casualty, with a 4 per cent average rise in public emergency department presentations each year between 2008/2009 and 2012/2013, according to the Australian Institute of Health and Welfare.
One in four people heading to the waiting room is admitted to hospital for further treatment. Men account for just over half of all presentations at casualty departments, and of these, most are aged 15 to 24 and arrive on weekends.
Veteran emergency physician Dr Mike Cadogan, whose blog, Life in the Fast Lane, attracts more than 1 million hits a month, says the ideal casualty candidate is someone with a potentially life-threatening problem that can be reversed. But cases aren't always as simple as they may seem.
Cadogan recounts the story of a man upset at medical staff after arriving at casualty alone, demanding medical treatment. Doctors assessed him only to discover a large brain tumour that had sparked erratic personality changes.
Another elderly man was found dazed and repeating himself outside a memory clinic. He wound up in casualty, where savvy doctors discovered he wasn't seeking treatment for poor short-term memory but had escorted his wife to the clinic before falling and cracking his skull, resulting in a brain bleed. Doctors performed neurosurgery to save him.
On a full moon, emergency staff often report an influx in the number and type of patients at the door.
“There's definitely an increase in the number of accidents that occur, and increase in the number of people whose psychiatric conditions become more obvious (during a full moon),” Cadogan says.
“When you see nine ambulances lined up, a couple of code blacks where security get called to people in the waiting room because they're unable to control themselves appropriately and at the same time the code bell goes off to tell you that a multi-trauma is on its way, that's the kind of full-moon effect.”
A 2009 observational study at the Calvary Mater hospital in Newcastle, published in the Medical Journal of Australia, reveals that of 91 patients with violent and acute behavioural disturbance, 21 (23 per cent) presented during a full moon “double the number for other lunar phases”. Sixty-six per cent suffered alcohol intoxication or psycho-stimulant toxicity. Five attacked hospital staff.
Cadogan says the casualty patient population ranges from the very young to the very old as well as “regulars” such as weekend night patients and the “post payday” population who have spent their money on alcohol and wound up very ill; those with psychiatric illness or people in the throes of cancer treatment.
Heart attack and stroke awareness campaigns have helped lift the number of people rightly seeking help, he says. “What we don't want is people struggling at home thinking things are indigestion, they'll pass, they don't want to bother the nice emergency doctors – they are the type of people we need to see.
“The stoic, stay-at-home 40-year-old male who is clutching his chest, sweating and pale, not wanting to bother anybody, not really wanting to call an ambulance, they're the people who end up becoming significantly unwell.”
A health information phone line is available to connect people with triage nurses and doctors, who can help make the decision about whether to go to emergency easier (seehealthdirect.gov.au/our-services).
When to go to casualty:
If you are injured
If you or you child becomes really ill, or suffers sudden onset of bad pain. Infants and young children can deteriorate rapidly.
If you have symptoms of heart attack or stroke.
Emergency departments are always open and are very busy.
For minor ailments see your GP or after-hours medical centres.