We love you, but we just might kill you ...

Globe&Mail - System frustrates team's best efforts
By CHRISTIE BLATCHFORD

TORONTO -- Mondo Fasciani wasn't the poster child for the weaknesses of Ontario's hospital emergency-referral system.

The 76-year-old man had suffered a ruptured abdominal aortic aneurysm -- a ballooning of the body's main blood vessel usually caused by coronary artery disease -- and was already showing the early signs of shock when he arrived Tuesday night at North York General Hospital's emergency department.

But grim as his prognosis was, Mr. Fasciani probably had a shot at survival, and that he didn't get it is a source of dismay for those who loved him and those at the hospital who tried so hard to save him.

A ruptured aneurysm requires immediate surgical repair at the hands of a skilled vascular surgeon.

Yet despite the desperate best efforts of both hospital doctors and staff at CritiCall, the Ontario government program that is supposed to find immediate help for critically ill patients anywhere in the province who require high-level specialists, it took more than two hours before a vascular surgeon and a hospital bed could be found for Mr. Fasciani.

Shortly before midnight, a surgeon with the necessary resources -- an available operating room and an intensive-care bed -- was finally located at St. Joseph's Health Centre. But minutes later, just as the special critical-care ambulance arrived at North York General to take Mr. Fasciani to St. Joe's, he suffered a heart attack. He died shortly afterward.

"I do not understand what is happening in Canada in 2005 where a man can be admitted to a hospital and doesn't have even the remotest chance for survival because of lack of an available surgeon," Mr. Fasciani's neighbour, Esther Lefler, told The Globe and Mail.

Mrs. Lefler accompanied Mr. Fasciani and his wife Lisa, whom she described as "fine and lovely people," to hospital that night. Mr. Fasciani was seen immediately, she said, a fact confirmed yesterday by Tim Rutledge, the medical director of the hospital's emergency department. Because the family gave Dr. Rutledge permission to discuss Mr. Fasciani's case, he was able to speak about it to The Globe.

And, Mrs. Lefler said, the hospital staff "laboured mightily" to save Mr. Fasciani even as "the doctor frantically tried to reach a surgeon." Dr. Rutledge confirmed that too.

North York does have its own vascular surgeon -- "an outstanding surgeon," he said, who is on call more nights than most -- but who was on a rare evening off, so CritiCall was phoned within 15 minutes of Mr. Fasciani's arrival. "Our team fought desperately to save this man's life," Dr. Rutledge said, even after Mr. Fasciani suffered the heart attack. "In addition to phoning CritiCall, we tried some of our own calls. . . . We very often call Sunnybrook [Health Sciences Centre] because they're so close. They have two vascular surgeons, but they were unable to help."

Three times, CritiCall staff thought they had found help, and three times, the North York emerg doc was on the phone to a surgeon, giving him the details of Mr. Fasciani's deteriorating condition.

Three times, these surgeons didn't have the necessary support at their hospitals -- either they had no operating room or no staffed intensive-care bed -- and had to turn the case away.

"It is a frustration and a key source of stress for emergency staff," Dr. Rutledge said. "We look in the main to the downtown teaching hospitals who are funded for this sort of care, and more often these days their resources are inadequate to meet the demands."

But even so, he said, because staff immediately knew Mr. Fasciani was in grave trouble -- the family was advised to call in a priest even as the scramble to find a surgeon continued -- this was not the worst case. His people often have been left feeling more helpless.

"I can tell you," Dr. Rutledge said, "that we have had, and lots of emergency departments have had, cases where it's been hours and hours and hours before we can find a facility" and where patients with a good prognosis weakened and worsened almost unto death before the eyes of doctors and nurses.

The situation is particularly serious for patients requiring neurosurgery and vascular surgery, as Mr. Fasciani needed. "In one case," Dr. Rutledge said, his hospital -- in the biggest and most medically sophisticated city in the country and after many hours of CritiCall searching for a neurosurgeon -- "were going to have to transfer a patient to Sarnia."

He said that where with multiple trauma surgeons, CritiCall always knows which of the two adult-care hospitals in Toronto has available staff and beds, the protocols for neurosurgeons and vascular surgeons aren't nearly so straightforward. "It should be crystal clear who is going to take vascular emergencies on any given night," Dr.
Rutledge said.

Shelley Moneta, program director for CritiCall, confirmed yesterday it took staff two hours -- or about twice the average -- and three unsuccessful attempts before a vascular surgeon was found for Mr. Fasciani. CritiCall is able to solve the doctor-search problem with one call and in 10 minutes for 50 per cent of the 10,000 calls they get every year from Ontario hospitals, she said. "But there are times when the system is constrained," she said. "There are exceptions, and they concern us greatly." Fully 80 per cent of the time, Ms. Moneta said, CritiCall can find a specialist with calls to three physicians. But for the remaining cases, it may take as many as seven tries before a doctor is located. She agreed with Dr. Rutledge that the "processes for trauma cases are very straightforward," but said that making them equally clear for neurosurgery and vascular cases is a policy matter for the Health Ministry.

Esther Lefler understands all of this: that the hospital and its staff are not at fault; that CritiCall can work only with the resources it has at its disposal; that Mr. Fasciani was in big trouble. But she remembers the day, more than 30 years ago, when she and her husband Stan and their kids moved into a spanking new house in a spanking new neighbourhood and met Mondo and Lisa Fasciani and their children. There they were, one family Italian, the other Jewish, "in our brand-new houses with our brand-new families," and they forged a lasting and warm friendship. To see her beloved friend, still so strong, denied the chance to fight -- and he was a fighter, Mrs. Lefler said -- effectively bleeding to death over the course of two hours was just "appalling."

Mr. Fasciani, husband, father, grandfather and neighbour, will be buried on Monday.