Lost, and sometimes found, in the emergency department at Christmas

Last Christmas, I traded my cozy bed for a shift working in my hospital’s accident and emergency department. It was as packed as any other night.

In spite of the popular notion that emergencies over holiday periods tend to more accurately reflect the moniker “emergency” — if you’re well enough to open presents and stuff your face with Christmas dinner, you’re probably well enough to put off a trip to the hospital for another day or two — I encountered two distinct categories of patient, neither of which I’d categorize as emergencies. The common denominator? Lonely living environments.

The first lot I met and cared for over Christmas Eve and Christmas night came from nursing homes or sheltered housing. Shortages of workers, coupled with inexperienced and unfamiliar staff filling in for regular carers taking the holiday off, meant that many were throwing in the towel at the hint of unfamiliarity. I don’t blame them: Seizures, agitated and aggressive behavior, strange breathing, or unresponsiveness to being roused are frightening things for anyone to encounter.

But when you are trained to deal with these kinds of situations, and when your patient has a clearly marked care plan, a “do not resuscitate” order, or other end-of-life plan in place to avoid emergency admissions, it begs the question why emergency services are still contacted and these individuals are put through the trauma and rigmarole of the hospital circus.

Some of the patients, I sadly noted, came with concerns about neglect. While the charge nurse bellowed “HO HO HO, MERRY CHRISTMAS!” at the stroke of midnight over the loudspeaker, I was suturing the scalp of a man in his 80s with dementia who had fallen and split his head on a side table after trying to get to the bathroom in his nursing home. He laid on the floor bleeding for an hour before being noticed.

The second group included the lonely ones. Arthur (not his real name), who lived alone in government-provided housing, was a frequent flier in our accident and emergency department, having been seen there no fewer than 14 times in the past three months. Not a single one of those occasions represented either an accident or an emergency. On some of these visits, Arthur left of his own accord. Other times he was discharged by a clinician and returned home with reassurance and the odd new medication to try and abate his protests that his current ones don’t work, but which he also refuses to take.

For many patients — Arthur perhaps represents the tip of the iceberg of those with chronic health problems — the emergency department can act as a reassuring haven for both social and health complaints. Arthur has a multitude of the latter: a previous heart attack, insulin-dependent type 2 diabetes, kidney failure, cataracts, widespread arthritis, chronic back pain, vascular disease in both legs that augment this pain, COPD, asthma, anxiety, and depression, to name but a few on my automated list of his recent past medical history.

For whatever problem that’s causing Arthur the most concern at any given moment, the emergency department is always there, open 24 hours a day, seven days a week, 365 days a year. On this Christmas Day, he rolled in at 3 a.m. after calling an ambulance 40 minutes earlier because of shoulder pain.

What happens next is a painfully drawn-out conversation in which I explain that, according to his current prescription, Arthur has some fairly strong painkillers at home that were prescribed by a doctor. Arthur agrees. But he didn’t want to take them at home, alone, in case they didn’t work. He wants reassurance that someone can prescribe these strong painkillers for him now and watch him take them to make sure they work.

I am too tired to debate this logic. I offer him the painkillers, he accepts, and I send him for an X-ray of his shoulder at the behest of my senior physician. As I predicted, Arthur does not have a fracture but the same chronic, degenerative, osteoarthritic changes consistent with his symptoms now and on the previous 10 visits.

I go back to see him with some written information on shoulder exercises and leaflets on quitting smoking, but he’s already hobbled off into the frosty morning, no doubt likely to be seen again in the next fortnight with another such complaint.

I wanted to call him back in to check that his pain had improved, and at least have more time to spend with him to address what were clearly his concerns, though they were reassuringly normal ones. But with beds to be filled and patients to be seen, I was immediately distracted by the need to attend to a young woman with suspected norovirus. And so, in my busyness and fatigue, I momentarily forgot Arthur and the thousands like him with no one to go home to share their burdens.

Later, when I had a minute to reflect, I realized that Arthur must have been incredibly isolated to have come to the hospital on Christmas, a joyous holiday for many but what is likely to be one of the loneliest times of the year for those who have no one to turn to.

How can we address this? With the landslide Conservative Party election in the United Kingdom’s most recent general election coupled with longstanding political instability (see Brexit), I fear for the thousands of patients across the country with limited social care resources, all the more exaggerated at times of short staffing, such as Christmas.

According to a 2017 report commissioned to mark the 70th “birthday” of the U.K.’s National Health Service, spending for adult social care in the U.K. has fallen by almost 10% in just six years, and a funding gap for social care of £18 billion will open up by 2030 or 2031. The implications are undeniably stark: Informal caregivers will no doubt continue to absorb the majority of the strain. Indeed, 75% of those surveyed said they had not received any support or service which allowed them to take a break of between one and 24 hours from caring for a family member or loved one in the preceding 12 months. It was anticipated even then that cuts in social care spending by local authorities have led to increased use of emergency services by people aged 65 and over.

The U.K. isn’t alone in this precarious situation. Globally, social isolation contributes to mental health issues, and though there is growing recognition of the role that socialization plays in promoting recovery from interventions ranging from major surgery to chest infections, isolation is a pervading problem that leads to dependence on first-line health care services. Hospitals, and especially accident and emergency departments, end up as literal and figurative Band-Aids for those who are struggling, poor substitutes for the robust community resources that could preempt such problems in the first place.

I write not to present solutions but to seek them, pertinently reminded that, for the first time since qualifying as a physician, I won’t be working in the hospital this holiday period. More funding for the social care sector is desperately needed to address and prevent the need for emergency services to buffer shortages, and all the more so in times of austerity.

My thoughts, for now, will be for those working in emergency departments during Christmas time, the challenges they will encounter combating clinical and nonclinical situations, and the hope and comfort they will undoubtedly bring to those in need, even for a short a period of time.

Grace Hatton is a general medical physician and clinical research scientist based in London.