Wednesday, September 24, 2008


A man died in the ER department of a very busy local hospital on the weekend. A man who was sent to the ER by a community clinic where they were unable to help with his medical issue. The man was found dead in the waiting room approximately 34 hours after he arrived.

Today the details of this tragedy surfaced. This man was one of the homeless in Winnipeg who was a frequent ER visitor. He had a catheter that was blocked and was unable to drain urine from his bladder via that catheter. The autopsy showed he died of a bladder infection.

What also surfaced was that this man never registered at the triage desk in the ER so the staff did not know he was there. It also surfaced that the community clinic where he had been seen and sent to the ER in a cab from never called the hospital to say he was coming in.

Now, it is a horrible situation and should never have happened but who is at fault here?

One would think, that if you go to the ER with a problem, you have to go to the triage desk to let them register you and get you into the queue to be seen by a doctor. Or even a nurse. A plugged catheter can be easily replaced and the issue resolved, along with appropriate antibiotics to treat the infection. But this man did not bother to do that. He sat in the waiting room, getting more loaded with bacteria and septic by the hour, until he passed away. Unbeknownst to those around him, until someone finally noticed his lifeless form.

The ER staff at that hospital are extremely busy. It is a huge facility, with multiple hospitals rolled into one big conglomeration, and hundreds of people probably pass through that ER every day. If they don't know you're there, how can they help you?

The community clinic that sent the man there didn't follow up with any kind of contact to the ER. At least, that is what is mentioned in the news. So.... why did someone from that clinic not just call the ER and tell them they were sending this guy over and what the issue was? Why was there no follow up to see if the man had been attended to in the ER?

My opinion on this is that the man himself was the first one responsible for what happened. He'd been to the ER enough times to know that you have to present yourself at triage to be seen. He arrived in a cab, for gawd's sake, so he must have been well enough at that point to make it to the desk and tell them his story.

The second offender in this scenario is the community clinic, with lack of contact and follow-up with the ER. Continuity of care has to exist to ensure that things get done properly and in a timely manner. Health care is the one area where this is of extreme importance. Helloooo..... it obviously makes a difference between life and death.

I can't say that the ER staff are really to blame, but one would think that a guy whose been parked in a corner somewhere for a day and a half would be noticed by the staff at some point - hopefully before he's dead. But I haven't spent any time in that ER so I really can't say what it is like. I guess it really depends on how busy it is (and I do know that many ER's are crazy-go-nuts most of the time) and how observant the staff are; whether they are understaffed and overworked or whatever.

All I can say is, is that everyone needs to take responsibility for themselves. In all aspects of their lives. Don't expect someone else to look after you if you are capable of making decisions for yourself, cuz more than likely that won't happen. And if someone is NOT able to take responsibility for themselves, then someone needs to be assigned to do that, be it family or a worker in whatever capacity. And they need to follow through until everything is resolved.

It is a tragedy, and I am waiting for the legal fallout to happen. Will this man's family sue the hospital, or the community clinic? If they do, where the hell were they when he ended up in that clinic and then the ER? Who will be disciplined for this in the health care settings where this man was seen (or not)?

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