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A top-notch doctor says he has never had to diagnose as much cancer as in the Rotorua Hospital emergency department since he started there 18 months ago.
Emergency Department Chief Dr. Suzanne Moran (left) and Lakes DHB Director of Strategy, Planning and Funding, Karen Evison. Source: Local Democracy Report
By Felix Desmarais, local democracy reporter
Dr. Suzanne Moran said the emergency department “is not the right place to tell someone they have cancer.”
“I have never diagnosed so much cancer in the emergency department as here at Lakes.”
Dr. Moran’s comments were made in a presentation to the Lakes District Board of Health and followed the unusual step of the board last week of asking people to only attend the emergency department (ED) if symptoms were urgent, indicating that the Rotorua emergency department was “overwhelmed.”
Speaking to Local Democracy Reporting this week, Dr Moran, who previously worked in emergency medicine in the UK and worked for eight years in New Zealand, said that people often did not see chronic symptoms such as weight loss, changes in bowel habits or smokers. cough as possible symptoms of cancer until its advanced stages, at which time they would go to the emergency department.
“So they don’t realize, or sometimes it takes a whānau member to say ‘look, I’m really worried about you, we need to help you.’
Also, with more people heading to the emergency department rather than their GP for non-emergency medical care, it meant that cancer diagnoses were picked up there, rather than from a GP.
“We could end up being the people doing the chest X-ray that shows lung cancer, or we could be the ones pointing out the concern that they have bowel cancer.”
She said diagnoses can happen in emergency departments: “Sometimes it’s just obvious.”
Dr. Moran said it was “horrible” to have to tell someone they had cancer in the emergency department.
“We are trained to deliver bad news, but sitting down to someone and explaining a cancer diagnosis, when we don’t have the answers about what would happen next, or to whom we will refer them, or what is the treatment. Involve – it is very, very difficult for all, but especially for the patient.
“You want to be able to take your time with patients like this and be able to answer their questions and give them some time to process. Time is something that we don’t have much of in the emergency department.”
Lakes DHB Chief Operating Officer Alan Wilson said the percentage of people diagnosed in the emergency department compared to general practice was reported nationally and that populations in poor or high deprivation areas, such as Lakes, tended to qualify highly for diagnoses in emergency departments.
In some other communities, almost all cancer patients were diagnosed through their GP, he said.
Wilson said the key message for the community was to see GPs early when symptoms appear and participate in screening programs.
“The reality is that the data … says that people diagnosed in the emergency room do worse because they are presenting worse, they have advanced cancer, rather than early one.”
Te Aho o Te Kahu, executive director of the Agency for Cancer Control Diana Sarfati, said that nationally, more than 30 percent of colorectal cancer patients were diagnosed after presentation to an emergency department.
Nearly half of all registered people with lung, ovarian, liver and stomach cancers were diagnosed after a presentation at the ED, Sarfati said.
The proportion of emergency diagnoses is even higher for some of the less common cancers, such as pancreatic cancer.
Approximately 60 percent of all pancreatic cancer registries are diagnosed after presentation to the emergency department.
Diagnosing any cancer at the earliest possible stage was “critically important,” Sarfati said.
He encouraged people concerned about their health to discuss this with their GP.
“We also strongly encourage people to participate in the screening programs for which they are eligible.
“We know that an emergency department diagnosis is not ideal, as cancer is often more advanced and subsequent diagnosis affects treatment options and successful outcomes.”
Te Aho o Te Kahu was actively monitoring the proportion of lung and bowel cancer patients who are diagnosed through the emergency departments at each district health board.
“The agency will extend this work to monitor other cancers over the next 12 months.”
Rotorua Aroha Mai Cancer Support Services founder and manager Bubsie Macfarlane said the underlying issues driving overburdened emergency departments, and the cancer diagnoses within them, were similar.
Macfarlane said that if late-stage cancer were diagnosed in the emergency department, it would be “a horrible thing for a person to take in.”
He said that many poorer people, particularly Maori, were likely to put off visiting their GP because they were “just trying to survive.”
For some, it’s a choice between going to the doctor or putting food on the table, he said.
Macfarlane knew many people who got their cancer later than they would have as a result.
“Then one day, they are so criminal that they end up in the emergency department … because they don’t have to pay.”
Macfarlane said that more prominent screening programs would help, as well as improvements in health promotion.
He said the health system needed to work more with Maori to increase the likelihood of earlier diagnoses.
“For the Maori it is very personal when it comes to the body, and some doctors and nurses don’t understand it. They don’t understand how indigenous people accept things and what could be taboo.
“Unless you understand the culture, you cannot understand the person.”
He said Maori also had a role to play: “Maori must take care of Maori.”
Rotorua Hospital. Source: Local Democracy Report
Cancer Society medical director Chris Jackson said the cancer emergency presentation was “clearly a concern.”
He said patients diagnosed in an emergency generally had “more extensive disease” at the time of diagnosis, which could have worse outcomes.
Intestinal cancers, such as pancreatic cancer, have a high rate of emergency presentation, he said.
There was regional variation in emergency presentation rates, which could reflect poorer access to primary or secondary care diagnostic services, he said.
Lakes DHB’s director of strategy, planning and financing, Karen Evison, said emergency departments were under pressure, in part, due to previously stagnant funding in the face of a growing population.
“There are more people accessing what was a limited health system.
“Our population has grown significantly and we have not built a significant new health infrastructure.
“Additionally, our general population is becoming less healthy: obesity, smoking-related diseases.”
He said health was an area that “was always going to gobble up money” as it sought to keep up with population and technological demands, but more funds alone would not solve the problem.
“We need to think differently about the workforce we use, the places we go, how we engage people so that they want to take action that makes health easier instead of waiting until they feel really bad.”
Evison said that such a system-wide change was expected from the 2020 Disability and Health Systems Review, which he understood was “driving at the pace now.”
He said the agencies could work together, and were already trying, to address barriers to healthcare, such as cost.
Moran said there is no “magic pill” to deal with the pressure on emergency departments.
“It needs to be a smart, well thought out, system-wide solution that not only continues to do what we’ve been doing, but starts to think differently.”
He said that on particularly busy weekends, there could be 20 people in the Rotorua Hospital waiting room and every cubicle in the treatment area full.
“Sometimes you feel like you’re turning dishes. That’s the ER nurse’s skill. [or] doctor … but when we reach that tipping point like the one we reached a few weeks ago, it becomes impossible.
“Sometimes you feel like you’re just fighting fires, and fighting fires is not a good way to practice medicine … just running from one crisis to another.”
He said there are strategies to mitigate that risk and offload the system.
“Unfortunately, we have to focus on the sickest and the most injured in the department.”
She said that she and the board of health had heard comments from people last week about why they had to rely on the emergency department for treatment and that they were being listened to.
At the health board meeting last Friday, board member Ngahihi Bidois said that if more medical personnel could speak to you, or at least pronounce Maori correctly, it would be “a good place to start” to make hospitals be more welcoming to Maori and thus help address poor health outcomes of tangata whenua.
Board member Merepeka Raukawa-Tait said she thought it would be helpful to put “someone really linked [who] speaks Maori and is Maori “in the emergency department waiting room to help explain the resources, processes, and navigating the healthcare system to people.
“We have been talking about it for some time. It is time to raise these issues and address them without fear.”
