The Casino Shift by Brian Goldman

In The Casino Shift: Stories from an ER on the Edge, emergency physician Dr. Brian Goldman revisits life in the Emergency Department (ED), in a sequel to his 2010 book, The Night Shift. During these intervening 15 years, ED volumes have increased, as has the complexity of illnesses, waiting times for ED care, and long delays for admission to hospital. The ED has become the catch all for Canada’s crumbling health care system, as primary care has collapsed, and hospital bed capacity has been cut.

Dr. Goldman uses an imagined “casino shift” that starts in the early evening and extends until the next day to tell his story. A “casino shift” splits a long overnight shift staffed by one ED physician into two shorter shifts staffed by two ED physicians in succession. With this model, each physician would get some “anchor sleep” between the hours of midnight and six am. They were introduced in the early 1990s to reduce the stress and health-damaging effects of overnight shift work. Judging by the intensity of patient care, it is not clear that this strategy is effective.

I have known Dr. Goldman – Brian, since we were in the same medical school class of 1980 at the University of Toronto. He sat at the front of the class with his hand up asking questions. I sat at the back on the left, where I’ll admit, I often fell asleep. Since then, Brian has worked for almost 40 years in the ED at Mount Sinai Hospital in Toronto, as well as hosting the long running CBC radio show White Coat/Black Art.  In The Casino Shift, he digs deep into his career’s cache of stories.

The case of “Molly”, a mental health patient screaming on the ambulance stretcher in the waiting room sets the tone for the book.  Brian wades into the crowded waiting room and uses his portable Ultrasound machine, which attaches to his cell phone, to find evidence of abdominal bleeding.  This necessitates a rapid move inside the department and then to the OR for treatment of a ruptured ectopic pregnancy (pregnancy growing outside the uterus, which can cause life threatening bleeding). Brian explains in detail the resuscitation and treatment, which could be a story in The Pitt, but also uses this example to illustrate the dangers of ill patients in waiting rooms and on ambulance stretchers, which has become a weekly news item across Canada.

Each chapter has a dramatic ED case, which exposes broader issues in the health care system, outside the ED. We meet young and old patients, who get the diagnosis of cancer in the ED rather than from their family physician. The effects of homelessness, drug addiction, and untreated mental health conditions are manifested by patients treated by Dr. Goldman and his team. We meet several ED physicians across Canada, who share their stories and moral distress about the current state of their ER.  These include Dr. Trevor Jain in Charlottetown and Dr. Lori Beatty in Halifax who confirm that the ER situation at Mount Sinai is just as challenging here in the Maritimes. We spend time with Jennifer, a medical radiation technologist, responsible for obtaining X-rays, Ultrasound, CT scans and MRI scans that support ED care 24/7 and learn about shortages in her profession and the dangers and stress of overwork. Violence and racism directed against nurses and physicians, a dirty secret in health care, which up until recently was just an accepted part of the job, is addressed as well.

We do hear about solutions, such as the “flying doctor” Nik Sparrow in BC, who attends patients on scene in isolated settings, and the Virtual Emergency Room Rural Assistance (VERRAa) program, which provides real time remote support to ED nurses when a physician is not available. There is some discussion of the new models for primary care physician payments in BC and the Ontario initiative in primary care led by Dr. Jane Philpott, former federal minister of health, and Dean of Queen’s University medical school.

What is missing from the book is a broader and deeper analysis of the issues outside the ED, and how they can contribute to the future of Canada’s health care system. Almost all the interviews are with ED physicians, and we do not get the perspective from health care leaders or managers. The stories make this book an engaging read, but in the end the reader might be more worried and reluctant to go to an ED than they were prior to opening the book.  

In the final chapter, when Brian is leaving the ED, he comes upon his resident starting CPR on a patient who left the ED prior to completing treatment.   They work together to save his life, and Brian ends on a hopeful note for the future, based on the passion and commitment of the next generation of ED physicians.

The Casino Shift will certainly help Canadians understand the current realities of hospital EDs. Still, readers will need to look elsewhere for insight on how  to improve health care, and for advice on how to navigate a system near the breaking point.  

Doug Sinclair

I grew up in Southern Ontario and moved to Halifax when I completed Medical School
at the University of Toronto in 1980. For the first time, I felt that I had found a home. I
met a Maritimer- Paula, and we have been married for forty years and have three adult
children and three grandsons. We spent two periods of our married life in Toronto, with
the last adventure as a VP at St. Micheals Hospital, enjoying the big city, but are happy
to be back in Halifax.
I retired last year from a 45 year career as a front-line Emergency Physician and
Hospital Leader. I have seen the evolution of Emergency Medicine practice from
“working in the outdoor” to a key component of our acute care system. In addition, I
have had a number of leadership positions in two provinces where I have tried in a
small way to guide and shape progress in our chaotic acute health care system.
I am now in my second year of the MFA program in Creative Non Fiction at Kings
College in Halifax. I am writing a book of hope about the Health System titled
“Emergency – Stories of Solutions and Hope from 45 years on the Front Lines of
Canada’s Health Care System”