The Emergency Room Paradox

During my tenure as a hospital administrator, no department tested my patience, resolve, and sense of inadequacy more than Emergency Medicine. It felt like an uphill battle I was destined to lose. Despite repeated attempts, the problems in the emergency department remained stubbornly resistant to reform. If I were to identify one enduring regret from my years in administration, this would be it.

The most persistent challenge was the chronic shortage of trained medical officers. In practice, we ended up with three imperfect categories of doctors staffing the emergency department.

First were residents from non-clinical departments, drafted out of necessity rather than choice. Asking them to manage critically ill patients was like forcing a square peg into a round hole. They neither had the training nor the inclination. Department heads were reluctant to spare them, and when they did, we often found pathology residents manning the emergency room at night—uncomfortable, uninterested, and unequipped. Many were simply waiting out their hours.

To plug this gap, we appointed full-time medical officers on eight-hour rotas. Some, however, had spent decades working in peripheral health facilities without updating their skills. They had grown resistant to retraining and indifferent to change.

The third group comprised freshly graduated MBBS doctors. Many signed up not out of commitment to emergency care, but to earn a modest income while preparing for the NEET postgraduate examination. Their attention was divided—multiple-choice questions on their phones competed with patients gasping for breath. Turnover was rapid. Retaining them felt like trying to hold water in a sieve.

Emergency medicine demands teamwork across disciplines. Critically ill patients rarely arrive with neatly compartmentalized problems. They come with head injuries and fractured limbs, internal bleeding and hypoxia, diabetes and hypertension—all at once. What they need is coordinated care. What they often got was a game of hot potato.

Departments passed responsibility from one to another, each insisting the problem lay elsewhere. Patients languished in the emergency department for hours—sometimes days—while negotiations played out over their bodies. Despite endless meetings and personal intervention, solutions remained temporary, cosmetic at best. It felt like trying to extinguish a fire with a garden hose.

Some moments remain etched in memory.

A young man with severe head injury arrived after a motorcycle accident. His family screamed for help. The ward was understaffed, the resident nowhere in sight. I found him asleep in a call room. When woken, he confessed—without embarrassment—that he was a pathology resident and had no idea how to manage head injuries.

Another patient with multiple fractures lay in agony. Orthopaedics refused surgery until blood pressure stabilized. Medicine declined admission until fractures were addressed. Meanwhile, the patient suffered, unattended.

A man with an acute myocardial infarction received aspirin. The cardiologist was unreachable. The resident did not know what to do next. Time slipped by. The family panicked.

A gunshot victim arrived bleeding. Surgery was called. The team was “too busy.” The family grew hostile. The resident froze.

These were not isolated incidents. They reflected systemic failures—of training, coordination, and accountability.

Compounding clinical chaos was the emotional turbulence of anxious families. Emergencies arrive unannounced, often at night, bringing panic in their wake. Relatives demanded immediate answers and instant cures. Some pleaded. Others shouted. A few threatened legal action.

Their expectations were understandable. Our responses were often inadequate.

We struggled to explain uncertainty in moments that demanded certainty. Journalists called at midnight. Videos went viral. Images of crowded wards and exhausted staff circulated freely, stripped of context. I found myself firefighting—trying to limit damage, soothe families, and defend young doctors already stretched beyond their limits.

Despite empathy and repeated explanations, situations often spiralled out of control. We listened. We reassured. We followed up. But we could not always meet expectations shaped by fear, grief, and misinformation.

Looking back, the emergency department mirrored larger institutional weaknesses—broken hierarchies, siloed departments, poor communication, and acute manpower shortages. Fixing such problems requires more than intent. It demands trained professionals, shared ownership, and sustained leadership.

We did what we could. Often, it was just enough to keep the system limping along.

I consider this my greatest professional failure—not for lack of effort, but because effort alone was insufficient.

There is, however, reason for cautious optimism. New mandates from the National Medical Council now require every medical college to develop a dedicated emergency medicine department. This structural change may finally force progress.

Yet challenges remain daunting. There are only a few hundred trained emergency physicians in India and more than six hundred medical schools competing for them—alongside private hospitals with deeper pockets. We advertised three times. Not a single applicant came forward.

Emergency medicine demands sacrifice. Few are willing.

What did these years teach me? That leadership cannot compensate for systemic shortages. That medicine, especially emergency care, is unforgiving of improvisation. And that acknowledging failure is not weakness—but honesty.

I learned, painfully, that some battles cannot be won by intent alone. But they must still be fought.

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