The Infinite Game
THE INFINITE GAME
After working in ED for the better part of a year, I could definitely say I had a more realistic outlook on life as an emergency physician by that point.
Sure, the pay isn’t great, the working conditions are tough and the exhaustion is real. But despite all that, most of us get over it. Having said that, if there’s one thing that disheartens me, and most of my colleagues for that matter, including those who have been at it for years on end, it’s this: no matter how hard we work, no matter how many breaks we fail to take and no matter how long it’s been since we ate, drank or peed, it’s a thankless job.
And I get why. Despite all our efforts, people keep on showing up, people keep on dying. It’s an infinite loop that never ends. And, at the end of the day, it is our job.
An Endless Cycle
Imagine going to work knowing you have a predictable set number of tasks to achieve. You go in knowing how much work you have to put in. Maybe you even split the work and set some time aside for a break or two. Doesn’t really work that way in the ED.
Instead, you show up not knowing whether there are gonna be five or fifty cases on the rack. As a BST 1, it wouldn’t really be my responsibility to make sure every patient is seen and cared for as soon as possible. In the future, once I’d be leading an area, it definitely would be. So I had to start putting myself in the shoes of the lead doctor right from the very beginning, asking myself how I’d manage to be as efficient as possible with the limited resources I’d have.
But how can you fix anything when the world is doing everything in its power to crash and burn?That’s a question lead doctors have to ask themselves constantly in ED. You try to divert and mobilise your assets to maximise resources. Patients with higher priority need to be seen first. That said, if we’re drowning in high-priority patients, there isn’t much more to be done. All cases are triaged accordingly, and patients with the same ESI score are usually seen on a first come, first served basis, unless they deteriorate and need to be managed more urgently.
With fifteen patients complaining of chest pain, any one of them could be having a heart attack. But with only a handful of doctors, someone will be waiting. And that wait could be fatal.
The Fix
With emergency departments all over the world drowning in work, let’s just say I’m not the first person who has sat down and tried to come up with a solution. Better doctors than me have tried and failed. But still, it doesn’t hurt to wonder. So how do you go about fixing a broken system?
Add more doctors? Easier said than done. With the workload getting increasingly heavier, local doctors just weren’t enough to fill the gaps. That’s when we started recruiting foreign doctors. And while they usually do an exceptional job, one can’t expect someone who has just moved to Malta to immediately acclimatise to a new country, a new culture and, most importantly, a new language. That said, a helping hand is a helping hand nonetheless. As the Maltese saying goes, “Malta qatt ma rrifjutat qamh” which roughly translates to “Malta never refused any grain.”
Another way of bolstering staff numbers? In grave circumstances, doctors from other specialties may be summoned to ED to lend a hand, which is a debatable move given that they’re usually busy doing their own jobs. Arguably, we should be the ones cleaning our own mess. That said, as proud as we should be about our jobs, we can’t really use that as an excuse if it puts lives into jeopardy, can we?
So if there’s only so much a larger number of doctors can do, what’s left? Decrease patient numbers? When we’re in crisis mode, we either advise low-priority patients to attend a health centre instead, which is probably what they should have done from the very beginning, or we warn them that waiting times will reach double digits.
With some locals misusing our services, probably something we can blame on poor public health education about when and how to use emergency services, this feels like a losing battle more often than not. And that’s me not counting all the tourists we get on a daily basis who think of the ED as a walk-in clinic. Whether it’s lack of insight or a matter of practicality, some people bypass primary healthcare completely and head straight to our doors, even if it’s just a cold or a stubbed toe that ails them. And, given that we offer a public service that runs on the taxes everyone pays, we can’t turn anyone away, no matter how innocuous the complaint might be.
Then there’s the issue of time and space, something not even Dialga and Palkia can help us out with. Sometimes, we literally run out of cubicles. Mostly because we have a limited number of rooms, but sometimes it’s also because we get stuck. If a patient is unstable, or requires specific nursing care before admission or discharge, there isn’t much we can do. They have to stay there for a while longer. But sometimes, it goes beyond the patient’s actual medical needs. Like there not being enough beds in hospital. Or having to wait for relatives to sort out social issues. Or having to wait an insanely long time for investigations or reviews. The list goes on and on.
An Insider's Perspective
So yeah, it’s not the first time lead doctors have tried everything in their power to maximise our assets, only for us to still end up with a never-ending list of patients waiting to be seen. Talk about pressure and responsibility!
Of course, those of us who work in the ED understand the reality of the situation: while we’re juggling all these challenges, things can still go terribly wrong, even when we follow all the right steps. Unfortunately, the same cannot always be said about those outside the system.
People like to imagine emergencies as obvious things. Someone clutching their chest. Someone unable to breathe. Someone bleeding all over the floor. And yes, sometimes it really is that dramatic. But other times, the person who is about to crash is sitting quietly in a chair. Their observations are fine. Their ECG is not screaming at you. Their bloods are still pending. Their pain sounds vague, their story keeps changing and, at first glance, they look no worse than the twenty other people waiting to be seen.
That’s the terrifying part. With enough time, space, staff and resources, you can reassess, recheck, review and catch things before they fall apart. But when the department is drowning, when every cubicle is full, when every doctor is already seeing someone and when the rack keeps filling faster than it empties, risk doesn’t disappear – it accumulates. And when something does go wrong, the outside world often sees one patient, one wait, one outcome. They don’t see the full rack. They don’t see the other dying patients, the resus calls, the corridor beds, the phone calls to specialties, the missing ward beds, the delayed discharges or the staff skipping breaks because there simply isn’t time. They just see the tragedy.
And once that happens, everyone suddenly becomes an expert and the entire department is under fire. The general public, journalists, comment sections, people who can’t tell their ass from their oesophagus, everyone has an opinion on what should have been done, who should have acted faster and why it was all so obvious in hindsight. I’m not even gonna mention all the misinformation that’s usually published about what actually goes on, or the very relevant details that are sometimes conveniently left out. Throughout all of it, we’re placed under the watchful eye, and very verbal mouth, of the entire population. We are evildoers, negligent, murderers, satanists, useless, ignorant. We hear it all.
And, of course, when investigations or magisterial inquiries are carried out after such tragedies, they often end up pointing to the same uncomfortable truth: that things had been done correctly, that the main problem was lack of resources and that some outcomes might not have been preventable even with earlier review. Needless to say, we don’t need a magisterial inquiry to confirm everything we already know. But sometimes, the general public does.
And, just like that, the message we’ve always tried to convey is echoed across news outlets and social media: we want to help our patients, but we cannot do so properly without adequate resources, and we need them to help us if they want us to help them.
A Broken System
I know, I know. I sound like I’m antagonising the general public, the very same people we work so hard to help. But hear me out.
We suffer verbal, and sometimes physical, abuse all the time – especially when waiting times are long. People complain about how long they’ve been waiting, about seeing patients who arrived after them being attended to first, about their problem being more urgent than everyone else’s, about us not caring, about us being slow, about every single thing. Even the best of us let it get to us at times. Hell, it’s not the first time I’ve had to get security to escort someone out or threaten to get the police involved.
But don’t get me wrong. Anyone who has to wait for hours to be seen in pain has been wronged. Anyone who deteriorates while waiting has been failed by something. But more often than not, that something is not a single lazy doctor, a careless nurse or someone who couldn’t be bothered. It’s the system. It’s a systemic failure through and through. It’s the lack of space. The lack of staff. The lack of beds. The lack of flow. The fact that the ED becomes the pressure valve for every other part of the hospital, and then gets blamed when the pressure becomes too much.
We want to help our patients. We really do. But we cannot do it properly without adequate resources. And if people want us to help them, then at some point, they also need to understand what we’re up against.
Dealing with It
As discouraging as all of this is, working in a broken system that more often than not fights against us instead of fighting for us, there is one thing that helps me make sense of it and keep fighting the fight.
“It’s the infinite game,” one of the ED veterans once told me. We’re not playing to win. We’ll never save everyone, and people will keep dying. The point of the game is to survive, thrive and keep playing, to push each loss as far away as we can. As dismaying as that might be, working non-stop to empty the rack and help everyone while more patients keep coming in, it is also the nature of the job. As bleak as that sounds, it’s also why I have a job.
I can’t say it doesn’t get to me. But knowing we all do our very best helps me make sense of things.