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Chapter 1: What challenges do Canadian emergency rooms face?
Canadian emergency rooms are famously chaotic places and everybody's got a story. And today's guest has tons of emergency room stories. Dr. Brian Goldman is an emergency room doctor and the host of White Coat Black Art, which is a CBC show and podcast that's been going strong for over a decade. He's also a best-selling author.
His 2010 book, The Night Shift, is a memoir that tells stories of his experience working as an ER doctor in downtown Toronto. It's about the patients, the stories, the work conditions, the brutal grind. But it's also an unflinching look at the systematic issues of the healthcare system. That was in 2010, and a lot has changed since then. The casino shift is the spiritual follow-up.
And a damn good book.
Chapter 2: How did Dr. Brian Goldman come to write 'The Casino Shift'?
Brian Goldman is on the show today. This is Audiobook Cafe. I'm Jacob Szymanski. The Casino Shift is available on Libro FM and Audible. It's 11 hours long and narrated by Matthew Dostal. Here's a sample.
I've worked night shifts for four decades and found it stimulating for a lot of reasons, but also difficult because of its physical and mental impacts. Casino shifts are one tactic ERs are using to address those impacts. Not surprisingly, given the name, the idea was borrowed from casino employees who typically work a six-hour shift from 10 p.m. until 4 a.m. or from 4 a.m. until 10 a.m.
The theory is that having two doctors split the 12 to 14 hours of the night shift is better than having one work all night because it allows both MDs to sleep at least part of the night in their own beds when their bodies are telling them it's time to sleep.
That was a clip from the casino shift by Dr. Brian Goldman. Brian, welcome to the show. Glad to be here, Jacob. I am amazed that you find time to work in the ER, host a podcast that publishes weekly, by the way, and that's not even mentioning making time for the show. How do you make time for all of this? It helps if you don't sleep.
And if you read The Night Shift, I'm a veteran insomniac. I'm a professor of insomnia, although I think I sleep a little better than I did back when I wrote The Night Shift. But yeah, it helps if you don't sleep.
I mean, did the casino shifts help, you know, these six-hour shifts instead?
Yes, absolutely. The casino shift was not just, it was pilfered from the casino industry, but it was adopted by some very smart emergency physicians at QE2 Health Sciences Center in Halifax. And they actually started using it about 15, 20 years ago. So around about the time of the night shift was first published.
And it's not just, as Matthew said so eloquently in that excerpt, it's not just that you sleep a couple of hours in your own bed or two or three hours. You get an extra two or three hours of daylight where you're up and about. And the daylight exposure is so important to synchronize your circadian rhythms. And I can tell you, I did night shifts back when I started working Emerge.
I did 10, 12 night shifts a month. And there's nothing more debilitating than doing a run of three or four night shifts in a row, which I used to do. You're cognitively not completely there. Whereas when you do a casino shift, you are there. You're sleep deprived, but you're much more cognitively on point, on focus. And I can tell you that they did surveys in Halifax.
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Chapter 3: What is the concept of casino shifts in emergency medicine?
And if you've ever been to an urgent care center, you don't go at two in the afternoon. You phone at seven in the morning and on speed dial and keep dialing and dialing and hoping that you can get a slot because by eight o'clock in the morning, all the slots in urgent care centers are full. And so your only other option at that point is to go to the emergency department or wait another day.
And it's not just the six million Canadians who don't have primary care. Many millions more can't get a timely appointment. So by the time it takes to get an appointment, their condition is much worse. And where do they go? They go to the emergency department. It is the place where people who have severe mental health challenges go, people who have substance use, the unhoused.
And my friend and colleague, Dr. Al Drummond, who I profile, I do a whole chapter on the emergency department that he helped to build in Perth, Ontario. It punches way above its weight. It was one of those smaller emergencies that closed down for three weeks, broke his heart when that happened. I tell the story about that. He describes emergency departments as the canary in the coal mine.
And, you know, whenever he wants to to post pessimistically on X, he shows a photograph of a dead canary on on the road. I don't know why we. laugh at that.
That's poetic.
It's very poetic. But, you know, that's that's what I mean. It's the place where when you have no other place to go, you go. And it's also supposed to be the place that's that's supposed to be open when you're critically ill or critically injured. The emergency department is the place, the first place where the crisis in health care will visit.
And all of the things that we can talk about, the lack of beds, acute care beds in the hospital system, the lack of long-term care beds.
Family doctors.
Family doctors, the lack of nurses, etc. Whenever you have those compounded problems, compounded by 30 years of either underfunding or outright neglect, then you're gonna see it in the way emergency departments function. And so that's what we mean by an emergency department. Now, the picture of the ER today, 15 years ago, I wrote about hallway medicine and we've had hallway medicine for decades.
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Chapter 4: How do casino shifts improve emergency room operations?
You've got colleagues that are doing inspiring things, pulling off miracles, despite all kinds of obstacles. So Molly was a perfect example of just... diagnosing her in the nick of time. She's what I call the needle in the haystack. And when you have that busy waiting room, you might have five needles in a haystack. And you've got to have six cents. You've got to have the tools of the trade.
I have a portable ultrasound machine. And what I was able to do in her case was whip out an ultrasound machine from my pocket, connect it to my smartphone and use it to get pictures of her belly showing that it was full of blood. which meant that that we had to bring her in as quick as possible or she was going to die of irreversible shock.
She was going into shock and was getting worse and worse by the minute. And what I was trying to do by that archetypal story is say that that sometimes we don't make it. Sometimes patients don't make it because we don't get to them in time when you've got the kind of crisis that we've got.
And, you know, Jacob, you've probably heard people listening to this have probably heard about people who have died in the waiting room. while waiting to be brought in. You've got Prashant Srikumar, a 44-year-old Edmonton man who waited eight hours in an emergency department at Grey Nuns Hospital and died just shortly after he was brought in.
He had a cardiac arrest just shortly after he was brought in. And this is really happening. And I wanted people to understand that. I tell another story. about a young woman who has an infected kidney stone. And the thing about an infected kidney stone is that it's not just having a kidney stone.
If you have a stone that's blocking the flow of urine and there's an infection above that stone, that blockage, then that person can die of sepsis very, very quickly unless you, by one way or another, relieve the obstruction. And I talk, I tell the story of the race against time to find somebody who can fix that before this young woman died.
And so that's how I chose the types of stories that I wanted to tell.
Now, when you're saying all of this, it's not looking good. Times are rough for patients, for healthcare workers, for everybody involved. How do you hope your readers react to this book and what you're pointing out?
By two words, Jacob. And these are two words that were spoken to me shortly after my radio show, White Coat Black Art, first came on the air, the first 10 episodes in the summer. And the executive producer of the then executive producer of another venerable CBC show, Ideas,
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Chapter 5: What is the current state of emergency medicine in Canada?
Now, the good news is he was on our show, and a few weeks later, he was one of 391-odd physicians who were invited. to apply for permanent residence. And we think we had something to do with it because the criteria that they used to select those 391 physicians seemed like they were tailor-made for our physician. Our physician, his name is Dr. Michael Antle.
And so that's something that we can do in a hurry. We can bring nurses in from the United States in a hurry. But of course, that's going to cost money, Jacob. So we have to pay higher taxes. We have to be prepared to pay higher taxes. And I'm not naive with the way the world is turning. We seem to be turning to war. We have authoritarian governments that are waging wars.
They're happening now as we speak. The United States is now involved in a war with Iran that nobody saw happening six months ago. And it may well be that developed nations here and in the European Union, for instance, are going to have to be spending a lot more money on defense.
Then they had counted on they were enjoying the peace dividend and maybe they're going to have to spend more money on defense and maybe there'll be less money for social programs. But I'm not going to kid you. It costs money to run a health care system. So. So, yeah, we need those things. Can we make things work better and more efficiently in the emergency department? Yep.
I spend a lot of my time boning up on patients online through Connecting Ontario, through online. I can get discharge summaries and I can get CT results and MRI results and lab tests. Well, we need an app that can aggregate and summarize medical histories for me. Anybody who thinks that that doesn't exist, that exists out in the world.
You can go to ChatGPT or Claude right now and can get a quick summary of any book you want to read. Easily. Yeah, easily. So we should have that now. I should be able to bring my smartphone into the room with me, record it. and get history and physical. I can just be dictating the results as I go. I don't need a human being to act as a scribe. A machine can do it for me.
We need to get that now because I can cut the time that I'm spending just reading things. by 90%, maybe by 95% so I can spend more time seeing patients and bring them through the system faster.
So there are things that we can do that won't cost a lot of money, but, you know, we're hyper fixated on privacy, on patient confidentiality and privacy, and we're terrified that records are going to get out there. So put the guardrails up. and make sure that we're able to take advantage of these technologies to work faster. You know, there are other things that I talk about in the book.
I think we need to have an adult conversation about private for profit, you know, private pay medicine, because it will either come in one of three ways. It'll either come by stealth. Or it'll be like it'll be sneak up on us, maybe by governments that want to cut back on publicly funded services.
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Chapter 6: How does patient access to emergency rooms impact healthcare?
Dr. Brian Goldman, thank you so much for your time. It's been a pleasure speaking with you. Likewise. That was Dr. Brian Goldman, the author of The Night Shift and his latest book, The Casino Shift. That's all the time for this edition of Audiobook Cafe. The show airs Fridays and Saturdays at 1 p.m. Eastern on AMI-audio, but we're also on all the big podcasting platforms.
You can email us at audiobookcafe at ami.ca. And you can also follow us on Instagram at AMI Audiobook Cafe. I'm your host, Jacob Chymanski. Happy listening.