Not every emergency Is an emergency

THE emergency department often tells only one version of the night. A child with a mild fever sits in her mother’s arms. A young man rubs the back of his neck because his tension headache worsened after a long day at work. A woman with acute gastritis scrolls her phone, hoping her number moves.

The hours pass and someone records the scene and uploads it online. The comments fill with frustration and anger. When illness appears suddenly, everything feels like an emergency, so every delay seems unfair.

The camera, however, never shows what is happening behind the critical zone doors. In that unseen space, a man from Putatan clutches his chest, his face pale and covered in cold sweat. His heart muscle is dying because a coronary artery has closed. Every minute of this Myocardial Infarction kills more tissue, and the team rushes to give oxygen, aspirin, ECG and prepare for thrombolysis. Nearby, a motor vehicle accident victim referred from Hospital Papar lies on a stretcher with polytrauma. His abdomen is rigid, and his clothes soaked with blood. The medical team works rapidly to stabilize him before his pressure collapses. At the same time, a stroke patient from Tuaran is rushed for an urgent CT brain. His speech is slurred, one arm weak, and the race begins to determine whether this is a bleed or a clot because the window to save his brain is narrow.

None of these scenes appear on Facebook. Yet they are the reason the emergency department exists. It is open 24 hours, but it was never meant to function as a 24-hour clinic.

Malaysia uses the Malaysian Triage Scale (MTS) 2022, which sorts patients into 5 levels. Level 1 is resuscitation, Level 2 is emergency, Level 3 is urgent, Level 4 is early care and Level 5 is routine. However, most hospitals simplify this into color-coded zones the public recognizes. Red zone means life threatening and needs immediate attention (0 minute). Yellow means potentially dangerous and requires timely treatment (under 30 minutes). Green means stable and safe to wait because the condition is not immediately dangerous.

Being triaged as green is often misunderstood as being unimportant, but it is none of these things. It means condition is not life threatening at that moment. Triage protects stable patients from being placed beside someone bleeding heavily or struggling to breathe. It also protects the person whose life depends on not waiting behind someone with a mild fever, headache or even simple upper limb fractures.

The usual indicator for non-critical (green zone) care is about 90 minutes. In reality,  especially in Sabah, waits stretch longer because red and yellow cases consume most of the manpower. Long waits are not a sign of neglect. They are the clearest symptoms of a system under strain. Studies across Malaysia showed in one teaching hospital, 62.1% of emergency cases were non-critical. At Hospital Universiti Kebangsaan Malaysia, 38.3% were non-urgent. Sabah reflects the same pattern. At Hospital Tuaran, 318 out of 457 cases were non-urgent, nearly 70% of that night’s attendance. These were cases of flu, mild fever, headache, gastritis and chronic pains that could have been safely seen at primary care. When non-emergency cases dominate arrivals, even the best emergency team cannot move faster.

Sabah’s hospitals carry an added pressure. The emergency department does not only handle new arrivals but becomes a holding space when wards are full. It is not unusual for patients to wait one to two days for a ward bed, and in difficult weeks that wait stretches to four or five days. When wards are full, emergency beds cannot be cleared, which leaves new patients waiting in chairs, wheelchairs and even along corridors.

This is the burden the public rarely sees. Overcrowded emergency departments are not just uncomfortable.

International and Malaysian studies show overcrowding increases mortality for time-sensitive conditions like stroke, sepsis and trauma, with delays in antibiotics, imaging and stabilization leading to worse outcomes. This is the hidden harm behind long green-zone waits.

Health-seeking behavior also plays a major role. Many Malaysians go straight to the emergency department because they think it is faster or assume that Klinik Kesihatan is closed, full or slow. Some believe hospitals provide stronger medicine. Others simply do not know which symptoms count as emergencies. These are not personal failings. They reflect gaps in public health communication and Sabah’s unique geography.

Rural communities often have limited clinic access after hours, so families travel directly to hospital even for stable conditions. Major hospitals like Queen Elizabeth Hospital (QEH), QEH II, Sabah Women and Children Hospital (SWACH), General Hospital Tawau, and Duchess of Kent Sandakan Hospital absorb referrals from across the state, increasing crowding and stretching manpower.

People also worry about being turned away. Stories circulate about patients being “rejected” at triage, but the truth is more measured. No one is turned away without assessment. Everyone has their initial assessment and vital signs checked and is triaged. Only after this process will a stable patient be advised to seek care at a clinic instead.

Part of understanding this issue is recognizing that not every medical problem needs hospital-level care.

Sabah has Klinik Kesihatan that runs extended services until 9.30pm on weekdays and weekend openings for non-urgent conditions from 9am until 1.00pm. Klinik Komuniti, which operates daily and even on public holidays, provides extended accessibility for mild fever, cough, flu, gastritis, sprains, rashes and other stable illnesses. These extended options exist so people can receive timely care without adding pressure to emergency departments that must prioritize critical cases.

Cost often drives people to hospitals, yet many do not realize it is affordable and even free options exist.

Skim Perubatan Madani allows eligible B40 households to receive free acute primary care at selected private GP clinics, covering consultation, basic treatment and essential medications for common non-emergency conditions. PeKa B40, available to Malaysians aged 40 and above, offers free screenings, blood tests and follow-up at government and private clinics. More than 163,000 Malaysians have already benefited, yet many still do not know they are entitled to these services. These schemes ease pressure on emergency departments and bring care closer to communities.

The Ministry of Health has been working to reduce overcrowding through short-stay wards, fast-track pathways and digital queue systems in primary care. Planned hospital expansions in Sabah aim to relieve the load on tertiary centers, yet lasting solutions also depend on long-term structural investment. The question of MA63 revenue returns, including the long-discussed 40% entitlement, continues to shape Sabah’s ability to strengthen its health system. When political leaders take these commitments seriously and channel resources into hospitals, clinics and manpower, the pressure carried by emergency departments can finally begin to ease. Overcrowding is not a staff problem. It is a system problem that requires system-level will.

The purpose of this column is not to blame the public. It is to help us understand the difference between urgent and non-urgent problems. When someone has chest pain, difficulty breathing, sudden one-sided weakness, seizures, heavy bleeding or a sudden change in consciousness, the emergency department is the correct place. When the problem is mild fever, headache, abdominal pain, sinusitis, gastric discomfort, flu or chronic pain that worsens slowly, primary care is faster, safer and more appropriate. This understanding shortens queues, reduces crowding and protects beds needed for the next heart attack or stroke.

I once spoke to Nazeri bin Jutais, a Senior Assistant Medical Officer at Emergency Department, Tawau General Hospital, about the realities behind the emergency department. He said, “What we face in Tawau is the same as in Kota Kinabalu. Overcrowding stretches the team every night, and people often do not see what really happens inside. This is why understanding how the emergency department works is so important.”

The emergency department will never be perfect, and some nights will test patience. But when we understand how the system works and choose the right place at the right time, we protect the very space that may one day save someone we love.

Footnote

Melvin Ebin Bondi is a PhD candidate in Public Health at Universiti Malaysia Sabah. He writes a weekly public health column for The Borneo Post.