Case history one:


Chris is a 58-year-old office worker who developed severe "indigestion" at work one Wednesday morning in September. He began to sweat, and, at the insistence of his co-workers, an ambulance was called.

The Toronto Emergency Medical Services (TEMS) responded to the call with a two-man team of paramedics, who are trained to erect intravenous lines, interpret electrocardiographs and administer a limited number of drugs according to emergency protocols. Within eight minutes, Chris was loaded on to the ambulance with ECG evidence of an acute heart attack.

The paramedics administered aspirin and intravenous pain relief; on arrival at the emergency room at Sunnybrook Hospital, he was frightened and ashen-faced.

Dr Bruce Sawadsky was the attending physician on duty who assessed Chris in the "acute room" of the ER. He was given beta-blocker medication to further protect his heart from the evolving heart attack; a consultant cardiologist agreed with Dr Sawadsky that he should hold-off "clot busting" treatment. Instead, within 15 minutes, Chris was wheeled to the hospital's "Cath Lab" where a dye test of his coronary vessels revealed an almost complete blockage of his left main coronary artery.

As the heart attack was still in its early stages, the cardiology team inserted a balloon to compress the blockage - a procedure called angioplasty.

Chris spent the next 48 hours under close supervision in the hospital's Coronary Care Unit. After another two days in a regular ward he was discharged with plans for follow-up by a dietician, physiotherapist and other members of the cardiac rehabilitation team. Should he require non-urgent bypass surgery in the future, he could expect to be operated on within six weeks.

Dr Andrew McDonald is the chief of emergency medicine at the Sunnybrook and Women's College Health Science Centre. He described Chris's treatment as "not untypical". With a total of 10 consultants in ER, the unit does not depend on junior doctors for service delivery. The department does, however, have an ongoing shortage of nurses - up to 10 per cent of posts are vacant at any given time - but it gets by with agency nurses.

Unlike in the Republic, not all patients' emergency admissions come through the ER. "Known cardiac and cancer patients will come straight to the wards," says Dr McDonald. However, there is a trend for older patients with multiple medical and social problems to be routed through ER "to be sorted". Such patients can spend over 24 hours in the department.

A patient like Chris with acute cardiac problems who lived in rural Ontario could arrive at Sunnybrook via air ambulance. The hospital is the base for a fleet of fixed-wing aircraft and helicopters which attend major urban accidents as well as providing an alternative ambulance service for people living in rural northern Ontario. The hospital has a helipad adjacent to the ER and the consultants provide radio support to the paramedics on board.

The ER at Sunnybrook has between 40,000 and 42,000 patient contacts each year. Its admission rate is 23 per cent which, Dr McDonald says, reflects the complexity of problems seen by a major urban hospital. He hopes to see an electronic triage system in place next year which will improve the flow of patients through the unit and improve assessment of medical "urgency".

A computerised clinical-decision support system - which would streamline doctors' problem solving - is also in the pipeline.