Increasingly the Emergency Room has become over-crowded. Some people call this over-crowding a "crisis", to me it represents the inability of a system to recognize the causes and come up with positive solutions. To understand why this has occurred one must understand the system : 1) Most doctor's offices are open only 9-5 Monday to Friday, they are often closed on Wednesday afternoon; 2) When doctor's office's are closed for vacation or after hours the default for their patients is the ER; 3) The ER is the default for what ails society - the elderly nursing home patient, the homeless, the alcoholic, the abused, those with dental problems (as well as those with legitimate medical problems.) Since we don't have 24 hr dentists, social workers etc these people are often treated as medical problems instead of dealing with the underlying issues ie poverty, lack of affordable housing etc. 4) The public in general has a very low tolerance for pain and any form of disability. I routinely see people who have had a sore throat for 1 hour (85% of these are viral, even if it is Strep throat you have up to 7 days to treat with an antibiotic) or sore muscles after doing vigorous exercise 5) The public's perception of the ER is shaped by popular programs like "ER", Chicago Hope etc. These programs are not based on reality; in fact the 1 or 2 occasions I have watched these programs I tried not to laugh too much - they can't even get the doses of medications right. If you want to watch a real ER show watch TLC's Trauma Life in the ER 6) The ER is an after hours pharmacy - I am amazed by the number of people who routinely come to the ER because they don't have things like Tylenol, Advil etc. To put this in context each visit costs the system $200 but because the system is perceived as being free people abuse it. 7) Only doctors can see patients in the ER - hence if you have only 1 or 2 doctors and 100 patients to see them the most critically ill are going to be seen first - this is called triaging. Needless to say patients, nurses and physicians all become a bit testy. The making of the ER crisis began in the Winter of 1999. It had been an unseasonably warm Fall and Winter and there was little if no snow by Christmas. As the world waited breathlessly for the new Millenium an influenza epidemic had broken out. To add insult to injury Christmas fell on a Saturday which meant most of us had the Monday and Tuesday off too. Physicians like many people in the population at large decided to have an extended holiday closing their offices from Friday, December 24th, 1999 until Tuesday January 4th, 2000 - a total of 10 days. The ER as the default became overwhelmed - a crisis was created. This prompted government to act - the influenza vaccine was provided to all in the Fall of 2000. There was little flu this year but I would attribute this to the much colder winter and not the mass vaccination. The government has also tried to tweak the system by adding things like Telehealth in the Toronto area, paying physicians an hourly rate etc, yet the waiting times in ER have changed little. When patients arrive at the Emergency Department they are triaged by a nurse. The Canadian Emergency DepartmentTriaging and Acuity Scale assigns a priority to each patient who presents and recommended wait times. For instance if you have chest pain you are assigned a Level 1 and should be seen right away. If you have a cold Level 5 up to 4 hours, earache level 4 up to 2 hours, mild/moderate asthma attack level 3 up to 1 hour and abdominal pain level 2 up to 15 minutes. When the ER gets busy it is extremely difficult to meet these guidelines especially if you only have one physician. I personally think they represent "ivory tower" medicine. They are skewed to a large extent by the addition of a pain scale. Solutions exist to solve the ER CRISIS. I recommend : 1) Encourage physicians to offer extended hours and after hours service - studies suggest patients would go; 2) Encourage physicians to work in groups to cover each other when they are on holidays/Wednesday afternoons; 3) Society has to understand that health is not created by our "health" system. Social issues, education and employment play a much larger role in determining health than does modern medicine. Dentists should offer clinics after hours and on Sundays; 4) The public needs to be educated regarding appropriate use of the ER. I am not in favour of user fees. 5) The public needs to understand that popular television programs are drama not reality based. 6) I am recommending that all households purchase the following medications : Benadryl (for allergic reactions), Acetaminophen (Tylenol) and Ibuprofen (Advil) for pain, Aspirin in case you are having heart attack (reduces your chance of dying), an ant-acid (I like Gaviscon but Maalox works too) in case you have eaten too much chili or drank to much beer and now have heartburn and finally Gravol in case you have stomach cramps or vomiting (an oral form and a suppository form is ideal). 7) I have worked 7 years in a rural ER and I have noticed that the ER nurses are very competent. Medical directives describe a scenario, tests to be performed and appropriate management. For example A 20 year old female who has burning when she pees. The medical directive would suggest doing a urine dipstick and if positive treating with a certain antibiotic (typically Septra) I believe ER nurses could easily manage 80% of all ER patients (Triage levels 3, 4, 5). The Emergency Department I work in (Four Counties - Newbury) was the first in Ontario to hire and utilize a nurse practitioner. Adrienne Fulford (who now works at our community health centre in West Lorne) was the first NP to work in the ER setting. I believe NPs could look after triage Level 2 patients and act as a resource for the ER nurses. (A recent report showed how poorly NPs were used in Ontario) In the system I envision physicians would only look after the critically ill, thus utilizing their skills most effectively. They would also act as resource to the NP and ER nurses on difficult cases. How long would it take to implement this plan - 3 months if there was political will. The medical directives already exist. I would suggest a meeting of the Ontario Medical Association, Registered Nurses Association of Ontario, The Nurse Practitioners Association of Ontario and the Ministry of Health and Long Term Care. I would be happy to act as a facilitator in these discussions.