Rotorua Hospital emergency department diagnosing cancers

8:19 am on 21 November 2020

A top doctor says she has never had to diagnose so much cancer as she has in Rotorua Hospital's emergency department since starting there 18 months ago.

Head of Emergency Department Dr Suzanne Moran (left) and Lakes DHB strategy, planning and funding director Karen Evison.

Head of Emergency Department Dr Suzanne Moran (left) and Lakes DHB strategy, planning and funding director Karen Evison. Photo: Andrew Warner / Rotorua Daily Post via LDR

Dr Suzanne Moran said the emergency department "is not the right place to be telling someone they have cancer".

"I have never diagnosed so much cancer in the emergency department as I have here at Lakes.''

Dr Moran's comments were made in a presentation to the Lakes District Health Board and followed the board's unusual step last week to call for people to only attend the emergency department (ED) if symptoms were urgent, stating the emergency department at Rotorua was "swamped".

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 people often didn't see chronic symptoms such as weight loss, changes in bowel habits or a smoker's cough as possible symptoms of cancer until its advanced stages, at which point they would go to the emergency department.

"So they don't realise, or sometimes it takes a whānau member to actually, kind of, say 'look, I'm really worried about you, we need to get you some help'."

Additionally, with more people heading to the emergency department over their GP for non-emergency medical care, it meant cancer diagnoses were picked up there, rather than by a GP.

"We might end up being the people that do the chest x-ray which shows the lung cancer, or we might be the ones that flag the concern that they've got a bowel cancer."

She said diagnoses could occur in emergency departments: "Sometimes it's just patently obvious".

Dr Moran said it was "horrible" to have to tell someone they had cancer in the emergency department.

"We are trained to give bad news, but sitting somebody down and explaining a cancer diagnosis - when we then don't have the answers about what would happen next, or who we're going to refer them to, or what the treatment's going to involve - is really, really hard on everybody, but particularly on 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 a lot of in the emergency department."

Lakes DHB chief operating officer Alan Wilson said the percentage of people diagnosed in the emergency department as opposed to general practice was reported nationally and populations in poor or high deprivation areas - such as Lakes - tended to rate 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 go early to GPs when symptoms arose and to participate in screening programmes.

"The reality is that the data ... says that people who are diagnosed in ED do worse because they are presenting worse, they've got an advanced cancer, versus an early one."

Te Aho o Te Kahu, Cancer Control Agency chief executive Diana Sarfati said nationally, more than 30 percent of patients with colorectal cancer were diagnosed after presentation at an emergency department.

Nearly half of all people registered with lung, ovary, liver and stomach cancers were diagnosed following an ED presentation, Sarfati said.

The proportion of emergency diagnosis is even higher for some of the less common cancers - like pancreatic cancer.

About 60 percent of all pancreatic cancer registrations are diagnosed after presentation at ED.

Diagnosing any cancer at the earliest possible stage was "vitally important", Sarfati said.

She encouraged people concerned about their health to discuss it with their GP.

"We also strongly encourage people to participate in screening programmes for which they are eligible.

"We know diagnosis at ED is not ideal, as the cancer is often more advanced and later diagnosis impacts on 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 emergency departments at each district health board.

"The agency will be extending 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 overstretched emergency departments - and the cancer diagnoses within them - were similar.

Aroha Mai Cancer Support founder Bubsie Macfarlane.

Aroha Mai Cancer Support founder Bubsie Macfarlane. Photo: File / Stephen Parker / Rotorua Daily Post via LDR

Macfarlane said if late-stage cancer was being diagnosed at the emergency department that would be "a horrific thing for a person to take in"

"It's a bombshell."

She said many poorer people, particularly Māori, were likely to put off going to their GP because they were "just trying to survive".

For some, it's a choice of going to the doctor or putting food on the table, she said.

Macfarlane knew a lot of people who caught their cancer later than they otherwise would have as a result.

"Then one day, they're so crook they end up in ED … because they don't have to pay."

Macfarlane said if screening programmes were more prominent that would help, as well as improvements in health promotion.

She said the health system needed to work with Māori more in order to increase the likelihood of earlier diagnoses.

"For Māori it's very personal when it comes to the body, and some doctors and nurses don't understand that. They don't have an understanding of how indigenous people accept things and what might be taboo.

"Unless you understand the culture, you can't understand the person."

She said Māori had to play a role as well: "Māori need to look after Māori".

Cancer Society medical director Chris Jackson said emergency presentation for cancer was "clearly a concern".

He said patients diagnosed in emergency usually had a "more extensive disease" at diagnosis, which could have worse outcomes.

Gut cancers, such as pancreatic cancer, had a high rate of emergency presentation, he said.

There was regional variation in the rates of emergency presentation which could reflect poorer access to primary care or secondary care diagnostic services, he said.

Lakes DHB strategy, planning and funding director Karen Evison said emergency departments were under pressure in part due to formerly stagnant funding versus a growing population.

"You've just got more people accessing what was a capped health system.

"Our population's grown quite significantly and we haven't built significant new health infrastructure.

"Plus, our population generally is getting unhealthier - obesity, smoking-related illness."

Rotorua Hospital.

Rotorua Hospital. Photo: File / Andrew Warner / Rotorua Daily Post via LDR

She said health was an area that was "always going to gobble money" as it sought to keep up with population and technological demands, but more funding alone would not fix the issue.

"We need to think differently about what workforces we use, what places we go to, how we engage people to want to take health-enabling steps as opposed to waiting until they're really unwell."

Evison said such system-wide change was expected from the 2020 Health and Disability Systems Review, which she understood was being "pushed through at pace now".

She said agencies could work together - and were already attempting - to address barriers to health care such as cost.

Moran said there was no "magic pill" to address the pressure on emergency departments.

"It needs to be a system-wide, well thought-out, smart solution that doesn't just continue to do what we've been doing but actually starts to think differently."

She said on particularly busy weekends, there might be 20 people in the waiting room at Rotorua Hospital and every cubicle in the treatment area full.

"Sometimes you just feel like you're spinning plates. That is the skill of the emergency nurse [or] doctor … but when we reach that tipping point like we reached a few weeks ago, it becomes impossible.

"You sometimes feel that you are just firefighting, and firefighting is not a great way to practise medicine … to just run from one crisis to another."

She said there were strategies in place to mitigate that risk and offload the system.

"Unfortunately, we have to focus on the most sick and the most injured in the department."

She said she and the health board had heard feedback from people last week on why they had to rely on the emergency department for treatment and that it was being listened to.

At the health board meeting last Friday, board member Ngahihi Bidois said if more medical staff could speak te reo, or at least pronounce Māori correctly, it would be "a good place to start" to make hospitals more welcoming for Māori, and therefore helping address poor health outcomes for tangata whenua.

Board member Merepeka Raukawa-Tait said she believed it would be useful to place "someone really linked in [who] speaks Māori and is Māori" in the emergency department waiting room to help explain resources, processes and navigating the health system to people.

"We've been talking about it for some time. It's time to be raising these issues and fearlessly addressing them."

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