CODE ZERO

Code Zero at Toronto East General Hospital

Daniel Harkins nestles his weary head against the cold steel rail of the hospital gurney. His mind is clear, his body a wreck. He is hungry. The next meal may be his last.

A life that began 89 years ago in Edinburgh, Scotland, appears to be drawing to a close this icy spring Thursday morning under the bright lights of Emergency at Toronto East General Hospital.

With neither family nor friends left to speak up on his behalf, Harkins suffers an inventory of despair by himself. Brain cancer, advanced heart disease, a blocked stomach, a debilitating bed sore on his backside. Last month he fell, breaking both hips. A schizophrenic for much of his adult life, he is also blind in one eye.

And — a small mercy — Harkins is hard of hearing. For all around him is noise. Two stalls away, a woman flanked by police officers howls as a nurse attempts to draw blood. She is under arrest. Screams can also be heard a few steps down the hall, where a patient recovering from a stroke is raising Cain.

Such is the din of "Emerg" at East General, where raw humanity rolls through the doors of triage in ones, twos and threes. They are the walking wounded, clutching heads that ache, knees that bleed, mothers and brothers who soothe. They are the prostrate, the frail, the fallen, fear etched in their tired faces, thin yellow blankets draping bird-like bodies.

They communicate their pain in a staggering array of languages — English, Urdu, Cantonese and Mandarin. Portuguese, Italian, Tamil and Greek. Interpreting their words and their maladies each day are a dozen nurses, half a dozen doctors and a legion of clerks, attendants and support staff.

But as this day unfolds, the incoming will exceed the outgoing in numbers triggering Code Zero, the hospital's shorthand for a bed crisis. When there are more than nine Emergency room patients waiting for beds elsewhere in East General, doctors are paged, patients reassessed. Those deemed safe to send home will be ousted early. When it's really bad — a backlog of 17 patients or more — it's time to start postponing elective surgeries.

But clogged Emergency wards are not the problem with the nearly $24-billion beast that passes for health care in Ontario. They are merely the most visible symptom of a dysfunction that stretches beyond Emergency to permeate a vast and uneven patchwork of hospitals, agencies and services.

A team of Toronto Star reporters and photographers watched the dysfunction unfold during a week in east Toronto in March. The Star team fanned out around the clock, following home-care staff, street health workers, nurses, family doctors and hospital specialists. Most of all, they followed patients.

And if there is a single lesson to be had in the week-long journey, it is this: There is no health-care system.

Or, more precisely, no single system; but rather, a confusing collection of wholly separate systems, each scrambling valiantly to serve its own notions of what is good for you, often at cross-purposes with the next, often unable to get the most basic information from one stage to the next.

So you pay your taxes, you believe in the Canadian health-care dream, and many of you get what you need — especially if you have friends or relatives who know how to make noise on your behalf, or you have a family doctor who goes the extra mile, or you have the money to pay for extra care.

If you don't, you probably end up in your local Emergency department.

And you will know, with every agonizing hour of waiting, that in 2002, the dream of timely and universal access to health care can be a long way away.

But that means nothing to Daniel Harkins, whose time is almost up. In the stark isolation of Room 11, an intravenous line feeds into an arm bruised blue and aching from five failed attempts to find a vein.

A nurse inserts a tube through the old man's nostril and into his stomach. Harkins kicks out his feeble legs, thrashing, moaning. The procedure lasts 23 seconds, but seems an eternity. In the end, a mustardy bile begins to snake through the tube. He is throwing up.

Ten years ago a public health nurse found Harkins wandering terrified through the Beach neighbourhood, tears streaming down his face.

A quick investigation revealed he was the victim of a landlady notorious for bullying her tenants into signing over their pension cheques in exchange for flophouse shelter. Senior Link, an East Toronto agency providing services to seniors, slotted Harkins for emergency housing. But by the time they went to retrieve him, Harkins had vanished.

In fact, he had been kidnapped. Police were called in to raid the landlady's other retiree tenements. Harkins was found shivering inside a locked closet, too frightened to press charges.

Perhaps it is no surprise that today, clinging to life with ragged, rasping breaths, he is wholly preoccupied with his wallet.

Clutching it tightly to his chest, Harkins stares warily through one good eye as strangers in his midst seek to bring relief. He has had his money stolen many times before. It will not happen again.

By week's end, as Harkins moves on, he will be remarkable mostly as a bed emptied, and therefore available to the next in line.

In total, 1,127 people pass through the doors of Emergency at East General during the seven days. The luckiest of the incoming measure their wait in mere hours, lightly medicated by the waiting room television that has been locked on the same channel since the remote control vanished two years ago.

Those most persuasive in pleading, bleeding, wheezing and sneezing their cases to the harried triage nurse get wounds stitched, blood checked, a throat swabbed, an arm or ankle set in plaster. And then they get out.

Others go home unseen, fed up with the eternal wait for their less than critical maladies. Still others go berserk, lashing out at nursing staff.

A few are tackled and shackled by the four unarmed protection officers who stand sentinel against the sick around-the-clock. One of those security guards was bitten during just such an encounter earlier this year and has the scar to prove it. Another is bitten during our stay.

But over the week, 172 people — nearly half of them seniors — will require admission. Some of these "admits," as they are known, stay the week, some several. A handful of the people we watched pass through the pale pink hallways of Emergency are still in the hospital, waiting, like so many fallen dominoes.

They are now among the 50 or so patients who, on any given day, have no business taking up a $534-a-day hospital bed at Toronto East General. They have improved to the point where they no longer need acute care, yet they have nowhere else to go.

Trapped by shortages — of nursing home beds, rehab beds, supportive housing, home care, mental health services — the bed blockers remain in limbo, crowding out more than a tenth of the hospital's 498 beds.

They fill the beds upstairs needed by the newly wounded coming through the sliding glass doors of Emergency. They force staff to park ailing seniors in pediatric rooms decorated for sick children. They leave cardiac patients camped out on stretchers, sucking back the stale air of Emergency, tinged alternately with the distilled breath of the drunk and the baby-powder bloom of newborns.

Some patients, like Wai Ching Wong, 91, will wind up playing the waiting game from both ends.

Wong arrives with broken ribs, having fallen down a flight of stairs at her son's Greenwood Ave. home. Her ordeal in Emergency is prolonged by a Code Zero, with staff scrambling to find beds — and in Wong's case, an interpreter, since she speaks no English.

She waits 30 hours in Emergency for a bed. Then she waits for a spot in a nursing home.

Good intentions abound in this crazy quilt of services. The good intentions of people like home-care worker Maria Raposo, who logs extra hours without pay to get the job done for clients who suffered through last year's budget freeze. The uncommonly good sense of Dr. Jane Pritchard, who is on a one-woman mission to restore the house call. The unenviable deeds of chiropodist Karol Prokocki, whose job it is to carve away calluses from the ravaged feet of Toronto's homeless.

They are but a few of the many health-care heroes to be found in the pages of The Star over the next seven days.

But not even their efforts can mask the larger cracks. Time and again we find smart preventive programs starved for funds — and boondoggles like the $10 million health centre that has yet to serve a single patient.

We find a hornet's nest of self-interest, where empire-building prevails in a political environment pitting non-profit versus profit, hospitals versus agencies, doctors versus everyone, it seems.

It isn't simply that left hand and right hand are out of synch. Sometimes, they're giving each other the finger.

Toronto East General, a sprawling, spider-shaped complex at the corner of Mortimer and Coxwell, is not what one would call a sexy hospital. It runs without telethons and $100-a-ticket lottery campaigns, without the five-alarm trauma or the cutting-edge surgery that attracts the television cameras. It is, like so many other community hospitals, reeling under the double weight of spiralling costs and increased demand, just getting by with what is very much a meat-and-potatoes service. It works, barely. Almost despite itself, it works.

Here at street level, our journey is populated by ordinary people doing extraordinary things. From every piece of the puzzle, chronically overworked nurses, doctors, social workers and administrators struggle to process the hurting hordes through barriers, shortages and poor communication.

Today, a few new barriers arise to join the usual assortment: a superbug outbreak haunts the halls of East General.

An increasingly common threat in hospitals, the viral infection must be beaten back, regardless of cost, before it claims vulnerable patients like children and the elderly.

More shocking still, a front-page headline in The Star announces the provincial government will seize control of the hospital, amid accusations of acute mismanagement by the board of directors.

Upstairs, new life is coming to supplant the old. People die here at a rate of two a day, compared to a birth rate of nearly eight a day. But last night alone brought seven babies at the hospital's newly minted birthing unit, where elegant decor and state-of-the-art accoutrements contrast starkly with the institutional, near-Dickensian squalor of the hospital's oldest wings.

A nurse confides her preference for the gleaming new birthing unit, where joyous news is the norm. Most of all, she takes comfort in the indisputable "innocence" of the newborn. Elsewhere at East General, staff strive to serve the needs of patients — the innocent and the not-so-innocent — by reducing their expectations of their patients, and of themselves.

Take Jackie Kyle. As East General's bed allocator, it is her job to conjure places to put people, moving them around like a chess player with too many pieces.

Kyle has short, ash-blonde hair, blue eyes and a smoking habit still going strong despite her 25 years at East General, the last eight as bed allocator. She once had the luxury of being "patient-focused" — able to consider age, gender and ethnicity as she went about matching patients more as roommates than medical cases.

Not anymore. In the late 1970s, East General had a capacity of 672 beds, served by a staff of 1,800. Today, after the closing of beds in the provincial downsizing of the late 1990s, there are 498 beds in active use, operated by a staff of 1,730. But the hospital sees more than double the patients it used to, thanks to the trend toward day surgeries and outpatient clinics.

Kyle's job has become a constant, seat-of-the-pants scramble for beds, most of it by e-mail and over the phone. From a little cubbyhole off the Emergency entrance, she handles something in the area of 300 calls a day.

"Hi, it's Jackie. Do you have anyone leaving today?"

When she arrives each morning at 7:30, she's greeted by a white board listing the day's challenges. Today, the day Daniel Harkins arrives, there are 129 patients registered in the Adult and Elder Unit, but there are only 101 beds. That means 28 A&E patients are in beds in other units — not the best way to deliver care. Already, 12 admits are waiting in Emergency, plus 10 day-surgery patients who will need somewhere to recover for a few hours after their procedures. There are no beds.

"That never changes," Jackie says with a laugh. "There are never any beds."

Which is not entirely true. There are empty beds at East General, dozens and dozens of them. Some of them sit draped in fresh linens in new units like Complex Continuing Care. Others are cloaked in dust, left behind in eerie, derelict corners of the sprawling hospital complex, awaiting renovations. There aren't enough nurses to staff those beds. So they are "closed" — sometimes for months, sometimes for years.

And still the patients pile up in Emergency. The Code Zero alarm is sounded at a chronic rate of three, four, five times a week, the sound of a state of crisis that has become the status quo.

Five days after arriving at East General, Daniel Harkins is losing it. Bedded down in surgical ward Room A508, he is lashing out at a nurse who is simply checking the lines running out of his arms.

"Every night," he rasps from behind an oxygen mask. "It's always you and your pills, pills, pills."

"You're not taking any pills," the nurse replies.

He is no happier to see a returning reporter. A few days earlier, he talked easily and asked for copies of the newspaper. Now, he ignores queries about how he is feeling. Silence envelopes the room.

Finally, he waggles one finger. "Leave me alone! ... Come back later."

Two and half hours later, a doctor records the time of death. Harkins died as he lived — alone.

Though Harkins had no money for a funeral, Leslie Clendenning, a Senior Link community worker who knew him well, takes the initiative to arrange one through social services.

A week later, in the slop and mush of an early April snowstorm, Harkins is bid farewell at the Giffen Mack Funeral Home on Danforth Ave. Eight women are here, all of them workers with Senior Link. A single spray of carnations adorns a plain grey coffin.

Clendenning shares some fond memories of the sweet-natured Harkins she knew. He was a favourite among Senior Link staff for the free history lessons he would share whenever they accompanied him anywhere. He would point to a building and rattle off its past uses, how it was involved in World War II. Even when he was well, he liked to take a taxi to East General, sit in the lobby and watch the world go by.

Clendenning did his shopping, even buying him underwear. More than once, he infuriated Senior Link staff by cutting up brand new shoes and taping them together again in order to accommodate his long toes.

With the onset of a schizophrenic episode, Harkins would transform into a terse, rude jerk. Until recently, he could anticipate those episodes and control his mood with medication. But in his final days, Harkins was unable to judge when episodes were affecting him.

Clendenning remembers how terrified Harkins was when he first fell under the protection of Senior Link. For months, he refused to go out alone for fear that his former landlady would find him and hurt him. Which is why Clendenning is seeing out his final wishes, including cremation. "He's a human being," she says. "He deserves the dignity of a service."

By the time Harkins is cremated, his ashes scattered over "common ground," his wheelchair has been passed on to another Senior Link client, an elderly woman having difficulty walking.

Back at East General, his bed is shuffled back into the mix. Within hours of his death, the empty spot goes to a man with gastrointestinal problems who waited in Emergency for almost two days.

The next day, a week after Daniel Harkins arrived at East General, there is yet another Code Zero. Jackie Kyle is working the phones, trying to find 23 beds. Around mid-morning, a nurse from Orthopedics walks into the bed allocator's tiny office to press for a bed. In mock desperation, she kneels on the floor and begs.

Jackie's answer today is Jackie's answer tomorrow.

"There are no beds."