Superdiversity, health needs and an over-burdened A&E

By Dr Silja Samerski and Dr Florence Samkange Zeeb

When Florence and I conducted our interviews with residents in superdiverse neighborhoods, quite a few reported having sought help in an A&E. Heavy back pain during the weekend, severe stomach ache in the evening, severe headache, the daughter breaking her leg – various health issues had prompted them to rush to the hospital. Thus, we concluded that the A&E should be an ideal site where the challenges of superdiversity and health care could be investigated exemplarily. After Florence and I conducted a provider interview with a nurse-in-charge of the A&E, I arranged a date for a longer visit in September. Some weeks later, on a bright Saturday noon, I arrive at the main entrance of the hospital. The nurse-in-charge welcomes me gently and leads me to the staffroom. A doctor and three nurses are sitting around, chatting and having coffee. At the moment, the situation is relaxed. Yet, they tell me, in the evenings or during the weekends, the A&E is regularly overcrowded (a worldwide tendency that is well described in the literature). Their work is daily madness, they imply, because roughly 80% of the patients showing up are “misusing” the A&E. Many of them have a migration background  - sometimes they do not know how to navigate the German health system, or they navigate it in their own fashion: They prefer the A&E because they can go there after work or because it allows them to see a specialist right away, without having to wait for weeks or even months. But also young Germans come because they do not know how to deal with minor health concerns and consider them urgent.Hospital emergency sign

During the five hours I spent at the A&E, I observed 13 different patient encounters triggered by very different health concerns: a finger dislocated during sports, a tick on a young boy’s neck, changing bandages, a little girl with a beginning sepsis, a woman who had overdosed paracetamol and ibuprofen, a man with a swollen face due to insect bites, a pregnant woman with a feverish infection – different people coming for different reasons, and correspondingly the interactions between health professionals and patients varied considerably from case to case. For this report, I describe two examples I consider especially telling, because these cases seem to pose the biggest challenges for both sides: Encounters where the professional rationality of the A&E, namely the treatment of bio-medically defined health urgencies, clashes with the self perception and ideas of help seeking patients.

Video surveillance allows the staff to observe corridors and waiting areas. As we have coffee, new patients show up. Knowing that I study superdiversity, the doctor points out that they look promising: They seem to have a migration background. I accompany the nurse to the registration office in order to observe the first encounter between patients and health professionals. Before they can come in, patients have to draw a number and wait in a special section until they are called. This is the first challenge where some patients fail and therefore have to be redirected. Yet, this time, they follow the signs and do well. When their number is called, four people rush to the office with a young woman sitting in a wheelchair. It’s a family with Turkish background. Only the husband and the patient are allowed to enter the office. Here, the nurse collects their personal and insurance data and, using a triage checklist, inquires about the severity of the woman’s health concern. This first encounter is decisive, because depending on the nurse’s assessment, patients are classified into five different categories: red (immediately), orange (10 min), yellow (30 min), green (90 min) or blue (120 min). In the last categories, patients sometimes have to wait many more hours than intended – one of our interviewees reported on having waited for 7 hours.

Now, the young couple is asked about the woman’s problem(s). Their German is that of a native speaker, they seem to have been born in the country. The young man, clearly worried, tells their story: His wife has got a fever, a headache and limb pains starting three days ago. When it started, they went to the A&E in another part of the city where she got an infusion. The next day, since she did not get better, they visited another hospital in a small town close to Bremen. The young man complains that they did not get any medicine to take home. Now, a day later, his wife is still sick. In the middle of the dialogue, a male nurse comes in and takes over the triage. He addresses the woman directly and insists that she replies herself. “He knows everything”, she authorizes her husband to talk on her behalf. But the nurse, in a friendly manner, puts it straight: “You can talk for yourself”. After she describes her symptoms, he directly tells her that she has an influenzal infection. “What can I take”, she asks, “maybe antibiotics?” The nurse calmly explains that antibiotics do not help, and that “chicken broth” is the classic household remedy. This however doesn’t find any resonance. Since there aren’t so many patients waiting, the couple is directly invited into an examination room where the woman’s blood pressure, her temperature and her pulse are checked. She has 39 degree fever, but everything else is ok. The nurse gives her another short lesson: he explains that fever is a healthy reaction but weakens the body, thus the best thing to do is to rest. Then, according to the standard procedure in the A&E, he wants to take blood. The woman refuses. She explains that she is relieved about her normal blood pressure and, in fact, looks revitalized. “I simply do not have this kind of machine at home”, she remarks. Before she can leave, however, she has to sign a form where it says she takes responsibility for not having her blood checked. The nurse brings the form, and she signs without hesitation. Together with her husband, and without the wheelchair, she leaves the room. The rest of her family receives her at the corridor and together they walk outside. As soon as they are gone, the female nurse who had started the triage procedure shakes her head. Three different A&E visits because of a feverish cold! Later, she explains to me that southern women are always immediately “half dead” on arrival, and wonders if this is to make their husbands worry.

A little later, we see two young men who look Afro-German strolling through the corridor. The nurse observes them with one eye because she suspects that they have overlooked the sign informing patients to draw a number first. After having inspected the coffee dispenser, the two men knock at the door. The nurse immediately tells them to first draw a number. They follow her instructions, draw a number and wait. Some minutes later, they are called and one of them, a young man in his 20ies, enters the office. He complains about recurrent stomach-ache during soccer training. “Since when do you have this?”, the nurse inquires. “Since three weeks”, he replies. The nurse gets visibly annoyed. “Do you have a family practitioner?” No, he hasn’t. Obviously he doesn’t know exactly what this has to do with his current situation and feels a little uncomfortable. The nurse makes clear that he is wrong in the A&E and should have gone to a GP during the week. The male nurse comes in again and continues the dialogue. When the young man locates the pain in his upper abdomen, both nurses remark: “There is nothing there”, referring to organs that could be the source of the pain. Finally, after having inquired about his eating and defecation habits, they suspect constipation, classify him as non-urgent and send him to the waiting zone.

As a medical sociologist, I am impressed by the apparent counter productivity of the health care system: It seems to create endless health care needs that can never be satisfied. In the 1970ies, the A&E of this hospital had one room and two beds. It worked - no one was denied treatment. Later, the department was expanded to seven examination rooms. Over the last five years these have been increased to 17. But regardless of its upgrading, it is obviously never enough. Could it be the case that the pursuit of health is like the pursuit of mobility? The more streets, the more cars and traffic jams. The more health care, the more health concerns and health care needs.

In the context of this mini-ethnography, I reflect on different cultures and practices concerning health, body and seeking professional help. Seen in this light, the encounters in the A&E are very interesting for our project on superdiversity and health: The meaning of suffering, the experience of disease and the expectations towards professional help seem to vary considerably from patient to patient. Clearly some patients mainly needed “technical” help - that is changing the bandage or splinting the dislocated finger. Others – and according to our provider interviews this is a growing number – rather needed reassurance: A father who had removed a tick from his son’s neck simply longed for a professional “everything ok”. The feverish young woman was revitalized after her blood pressure had been measured and found to be normal and walked out of the room relieved. How can the health system take this superdiversity of needs into account? The staff of the A&E has a rather simple technical solution on how to disburden their working place: They would like to have a normal GP office in the same rooms where they could refer the non-urgent cases. Apparently other hospitals have made good experiences with this solution. Yet, as urban neighborhoods increasingly become superdiverse, a diversification of health care provision might also be needed: Neither approaches to health and illness, nor office hours and access can be standardized when diverse needs of diverse people are to be met.

Posted on Monday 7th November 2016