Getting Up Close And Personal With Emergency Care, Canadian Style

Kaiser Health News

It had been a gorgeous day of cycling the rolling hills of Quebec's Eastern Townships. I wasn't traveling very fast when I hit a patch of gravel on the trail, but I went flying, landing hard on my left side.,

I sat up, holding my left arm. I couldn't lift it, and it hurt much more than could be explained by the cuts and scrapes that were dripping blood all over my shorts. Meanwhile, the base of the thumb on my right hand, with which I'd apparently tried to break my fall, was misshapen and swollen. I'd also injured my left flank, as I discovered when I tried to walk.

As my two friends propped me up and tried to identify our location for the 911 dispatcher, I awaited my first real-life encounter with the mostly government-funded Canadian health-care system.

As a health care writer, I talk with people all the time about their experiences navigating the system, whether in the United States or elsewhere. Writing about health care is different from writing about the arts, say, or sports, in one crucial way: When you write about health care, you're often left feeling profoundly grateful that you didn't have to experience firsthand the event that you're describing. But now my luck had turned, and I was about to get up close and personal with emergency care, Canadian style.

The ambulance arrived within 15 minutes, and I had a bumpy but uneventful ride to the hospital, a regional trauma center at one of the local universities. On arrival, we showed them my passport and American insurance card. Because I was a trauma patient, I was wheeled right in, just as would happen in a U.S. hospital. A nurse removed my clothes, cutting off my shirt since I couldn't move my arm. Another nurse drew blood.

At the request of a very young-looking resident, I moved various body parts on command and answered questions about what hurt. The resident, who was my main contact throughout the visit, also looked over my injuries, including checking my ears and eyes. She was friendly and kind, and kept up a running commentary in mostly fluent English explaining what she and others were doing. (One of my friends, a French-speaking Montreal resident, stayed with me and interpreted when the medical staff's questions or my answers were complicated.)

One of the most striking things about the exam was how little high-technology equipment they employed. Until I had X-rays made of my hand, hip, shoulder and knee, a blood-pressure cuff was the most advanced equipment I encountered.

Emergency department technology use varies, of course, in Canada and elsewhere. Still, clinicians at a trauma center in the United States treating someone with injuries similar to mine would probably wheel a portable ultrasound machine to the bedside in the trauma bay to scan for internal injuries, says Sandra Schneider, president of the American College of Emergency Physicians. They would also probably do CT scans, perhaps of my neck, pelvis and back, to make sure there were no bone breaks that didn't show up on the X-rays. Some of the tests might not be absolutely necessary, but "a lot of what [U.S. emergency physicians] do is because we are very frightened of getting sued, because we get sued so often," says Schneider.

In an analysis of data from 2003 to 2008, researchers at Yale and in Canada found that Americans were nearly twice as likely to get a CT scan during an emergency department visit as were Canadians living in Ontario.

In Canada, residents who go to the emergency department pay nothing for the visit, not even for X-rays or other imaging tests or for lab work, says Michael Schull, an emergency physician who co-authored the study on CT use. They also pay nothing for specialist visits and hospital admissions, he said.

"Hospitals aren't making any money off these tests," Schull says. "There's no incentive to do them, because they're not going to get paid for them."

After the X-rays were taken and I was wheeled back into the trauma bay (No. 13, but I figured I'd already had my bad luck for the day), the resident came to my bedside with a big smile on her face and said, "You really are in pain! You have three fractures!" Validation is nice, but I wished the news were different.

I had two fractures at the top of the humerus, the long arm bone that attaches to the shoulder, and another break in a bone at the base of my thumb. The shoulder breaks could be expected to heal cleanly, she said, but the thumb was slightly out of alignment and might require surgery. There were no broken bones in my pelvis or hip; the pain and difficulty walking I was experiencing there was probably caused by torn or otherwise damaged muscles, tendons and ligaments.

The trauma team referred me to an orthopedist to examine my shoulder and a plastic surgeon with expertise in hands to look at my thumb. Unfortunately, an orthopedist wouldn't be able to see me until two days later. (The chief orthopedic resident, however, stopped by that night and reassured me that it would be okay to wait.) I did get examined by a plastic surgeon that evening, but my friends had to drive me to a sister hospital several miles away to see him. Specialists, it seemed, were pretty thin on the ground.

According to a 2010 Commonwealth Fund survey of health care in 11 countries, 33 percent of Canadians waited six days or more to see a specialist when they were sick, compared with 19 percent of Americans.

My pelvis apparently did not warrant special attention. Since the injury seemed to be muscular rather than skeletal, the hospital staff would do nothing further to diagnose what was wrong, the resident said. Her recommendation for me — rest and exercise — would probably be the same no matter what I'd done to any tissue.

I couldn't argue with her reasoning, and if she was right, it was the sensible course. But what a difference in approach from what I would be likely to experience in the United States, Schneider says, where clinicians would probably have worked hard to nail down a definite diagnosis. I left with prescriptions for morphine, naproxen (an anti-inflammatory) and Tylenol.

Puzzled by my U.S. private insurance card, the billing person estimated that my care that night would cost 700 Canadian dollars (about $740) and charged my credit card. If it turned out I had been overcharged, she said, they would send me a refund. Yes, you read that right: overcharged.

Although comparing costs and bills is tricky, by any measure my evening in the Canadian emergency department was a good deal.