The Cut – look inside

Chapter 1

Saturday March 16, 2019

There’s something special about that smell – the Saturday night in the Emergency Department special blend. Stale alcohol and blood, rough-living bodies last washed at best a week ago, vodka and vomit thanks to an experimenting teenager. Faeces and urine leaked with unbearable embarrassment from someone who deserves privacy and dignity. Then the futile chemicals intended to clean and hide it all. 

Gloves, white overalls, waterproof boots – the cleaner finishes and no one would know there had been a pool of blood and vomit in the corner a minute ago.
‘Forty-two in the waiting room at the start of the shift. What chance do we have to catch up with that?’ grumbles a millennial nurse on her second shift in the ED.
‘Mummy it hurts a lot.’ Four-year-old girls don’t deserve pain.
‘Don’t worry lovely they’ll be here to look after you soon.’ Mothers don’t deserve to see their children waiting in pain.

All Jess Goldberg can think about is getting ten minutes to have some dinner. Maybe another five for a coffee.

Triage announces: ‘Incoming, three ambulances from a car crash. Police car versus stolen SUV. Seven minutes. One stable femur fracture, one chest, one intubated head injury with no blood pressure. Trauma team activated and code paged. Surgeon is responding.’
The police arrive at the back entrance. One either side of a dapper gent with a debonair moustache, three-piece suit, and briefcase. Who has a briefcase these days?
The intern picks up another crooked arm from the waiting pile and reflects, ‘I hope that guy I sent home with the headache is OK.’

The intercom interrupts with more volume than is really necessary. ‘Paging Dr Goldberg to Resusc. Urgent page Dr Goldberg.’ 
Goldberg breathes out. Dinner can wait, just like lunch did.

An executive-looking chap with fear all over his face has chest pain and needs to get to a stent ten minutes ago. His ECG looks like a line of tombstones.
Three nurses are scrubbed and waiting in resusc for the traumas, another ready to scribe, medical-student runners lined up. IV’s primed, blood ordered, radiographer on the way. 
‘Harvey, we may need you in resusc.’ Goldberg calls out.
‘No problem, I’ll finish the five things I’m doing in a flash.’ The professor smiles kindly at the pale panting old man whose wide eyes and cold hands say it all.
How does he never seem rattled? 

Raucous ambulance sirens, one maybe two. I don’t know why they need the sirens on in the car park. We know they’re coming, there’s no traffic. The paramedics park their horses, discard their spurs and wheel in the three from the RTA. Three wise monkeys coming through the door. Emergency Medical Services and police everywhere.
The first patient crashes on arrival, whiter than the sheet, drip tissued, tube down too far, and the EMS dude says, ‘He was fine a minute ago’.

‘Thanks Professor Pearce,’ says the old man’s daughter, ‘you’ve been so kind. We’ll be here when you get back…’ 
They’d been there ten hours already. Not going anywhere soon. No beds – again.
By tonight we’ll have a dozen in the corridors.
‘Mummy it’s getting worse and no one is coming.’
And in the waiting room toilet Alfredo Bipolar preens his stash, adjusts his waistcoat, and launches into top voice with accompanying stagecraft: 
‘Libiam ne’ lieti calici
Che la bellezza infiora,
E la fuggevol ora
S’inebri a voluttà.
Libiam ne’ dolci fremiti
Che suscita l’amore… ’

I guess Traviata is better than a sermon from Jesus Christ or a lesson from a Martin Luther King reincarnation like last week. Everyone hates shifts at triage.

Dead. Jess called it on the first trauma. No chance of winning there. They all shift their attention to the young woman with the head injury. The driver is the one with the fractured femur. Her pipe and paraphernalia are still hanging out of her jeans pocket.
‘What do you need me to do?’ asks Harvey.
‘Don’t worry about these,’ says Jess – ‘check the diabetic next door, will you, and see if those residents in Pod 2 need a hand. They’re week two and drowning in it.’

The adjacent cubicle is frantic with activity. Harvey parts the curtains and stands quietly at the end of the bed, surveying the scenario. It’s a technique and a discipline that emerged after his first decade or so in the business. No matter the level of chaos or the urgency of a patient’s problem, there is always time – always has to be time – to look and listen and see and hear what was happening. From that comes the ‘what to do next’. It never took long. In a matter of a minute, and sometimes seconds, he could see the picture emerge from the whirling activity.

In this room he saw a teenage girl on the trolley, maybe eighteen or nineteen. Sweaty, breathing rapidly, pink lips but a white ring around them, which was paler than the rest of her very pale skin. She coughed. Eyes wide, worried. No, frightened. IV lines in both arms, fluids running on one side, staff connecting an infusion pump on the other side. To his right in the corner were a mother and father. They stood silently and worried beside the nurse’s desk on which sat a pile of papers, a letter and a small diabetic kit bag open to reveal insulin injections and a glucometer for testing blood sugar.

So, thought Harvey, quite likely she was a newly diagnosed diabetic, still unstable, still learning about her disease, possibly less than one hundred per cent compliant with her treatment (as eighteen-year-olds are prone to be), possibly with an intercurrent chest infection, and parents who hadn’t yet come to grips with the impact of a serious chronic disease on the life of their otherwise perfect and beautiful daughter.

The registrar was a recent starter in the ED and Harvey hadn’t worked with her. He scanned the name badge – Amy Wong, Emergency Registrar. Amy looked about the same age as the patient and nearly as frightened, so Harvey stood beside her – an action which perceptively slowed her pace, extracting her from her complete immersion in the clinical setting, and required her to focus on this senior colleague, who was now in her space. Over the next couple of minutes Amy confirmed Harvey’s end-of-the-bed guesswork. She was on the right track although a bit flustered, so he left her to it, turning back as he moved towards the parents saying, ‘Amy, good job. I’d slow the fluids a little and hold off on the insulin infusion till we recheck bloods in half an hour. Some antibiotics for that chest infection would be good, and pop an oxygen mask on – OK?’ 
All under control.

‘Mr and Mrs McDougall?’ He’d spotted the name on the chart. A nod confirmed their status as worried parents. ‘My name is Harvey Pearce – I’m one of the supervising consultants in the ED today. I will be looking in on Sally today and helping look after her, but at this stage, Dr Wong has everything under control and we’re on the right track. Sally is going to be fine but will take the next day or two to settle down and restabilise her diabetes. She’ll be home by mid-week.’

Harvey saw the impact of those few words right there on the faces of Sally’s parents. Muscles that were taught relaxed a little, eyes that were wide now narrowed and the shoulders that were tense now eased to allow the couple to stand closer. Their two hands met and interlocked. Magic, Harvey thought. I do enjoy that part nearly as much as nailing the diagnosis. 
They talk for a few minutes and Harvey shows them to the relatives’ room; somewhere they could escape to if needed. The fear these parents have is different to the fear they would have for themselves or each other. More intense, more visceral, uncontainable. 

Harvey wanders off to Pod 2 and, for no particular reason, starts humming a vaguely remembered aria.
‘Don’t ya love Verdi,’ calls the drunk on the bench near the door with all the staccato impact of a classic De Niro line. Then he spouts, ‘Let’s drink from the goblets of joy adorned with beauty, and the fleeting hour shall be adorned with pleasure. Let’s drink to the secret raptures of the life I used to have… or something like that.’ 
He recited the libretto and dropped back to sleep. 
Harvey scratches his head and moves on, thinking, ‘He probably had a reasonable brain ten years ago. I need to get out of here, I have a plane to catch in the morning. Some sleep would be good.’

Three teenage-looking doctors sit at the desk, each on the phone trying to sell a patient to someone upstairs. Trying to con the bed manager into opening another bed. Trying to bluff the ward nurse with a threat to escalate to admin. Trying to call in a favour from an old mate now doing geriatrics. Trying to remember if there was a rule in ‘The House of God’ that would solve this problem? 
‘Go on James, you owe me, do me a favour and come down and admit this one. I’ve got another five on the go and haven’t had time to take a leak.’

Pain. Pain. Pain.
‘Mummy, please.’ Too tired to cry now, so just whimper a little. Why is mummy crying too?
The old man’s wide eyes relax. Departed. A painless freedom. No time to hold a cold old hand and ease the pathway, or to spend much time with a daughter who now has to say a last cheerio. But she half smiles through tears anyway and seems to understand. Maybe she’s been somewhere like this before. Maybe she knows what I would like to be able to do, what I would do, if I had time. He didn’t suffer but it’s not a nice place to die.

‘Clear,’ is the call from Ben, the team leader in Resusc Five, and two hundred joules jolt through the chest of a sixty-something, recently retired. Will he get to enjoy his retirement, or will his wife get the life insurance? He wakes up nearly as fast as he passed out and his monitor has changed from fibrillation scribble via flat-line to something looking like a sick heart.
‘What the… who kicked me?’ he asks with a dumb-struck look on his face. Winner.
The nurse and the consultant smile. That’s a good one. The medical student stands with her mouth open, no doubt thinking how remarkably similar the whole experience is to an episode of ‘ER’.

The psych registrar has arrived and says he’s looking for a tenor who stopped his meds and is back here courtesy of the police and a neighbour who couldn’t tolerate all-night opera.

The middle-aged mum with melanoma is polite. ‘Thank you, Alison, you’re the best nurse I have ever had looking after me. I know it’s hard for you guys here and if I had a choice, I wouldn’t come to the ED. You know what I mean. You gave me all the time you could, and you explained, and you were gentle. So, thanks.’

Alison smiles and walks away, groaning inside. ‘It’s just so noisy, that’s the real problem. If the noise would stop, then I could think, the patients could sleep, the rush would slow. I don’t know how anyone could work in this forever… How do you do it Professor Pearce?’
‘Don’t be such a defeatist,’ says Harvey. ‘Just think of the buzz you get, the lives you save, the difference you can make for someone in their most vulnerable, fear-ridden moment. What could be better?’ he says with a wry grin. 
She thinks he’s being sarcastic. No, his eyes say he’s serious.
Alison thinks to herself that crying in the toilet cubicle is pathological, but she can’t help herself and just hopes no one hears.

The waiting is over for the four-year old and her mum, and the injection works quickly. Her x-ray is fast-tracked and almost before she knows what’s happened, a young orthopaedic registrar called Sarah explains about broken bones and straightening them up and plaster and short sleeps. And then she’s awake again. Sarah smiles and mum stops crying, and her arm feels OK. And Sarah draws a big red love heart on the plaster and writes ‘from Sarah to a brave girl’.

But how can you deal with all this? It’s so frazzled, so full of queues and waiting and risk and systems that don’t work and staff that are too junior or too tired. People who care about the patients, but don’t know what to do to make it better. Others who don’t care and just worry about themselves – their next job or what the boss will yell at them or what the health department bureaucrats will say through their prissy we-really-do-care empathic expressions. It’s not surprising that things go wrong.
You know, most people get better; they heal. Recovery is what we expect when we are sick, and it is what the human body does. We’re here to help the process along and to turn things in the right direction. The real issue is that all of us know we could do a lot better. All this could be smoother, safer, simpler… more satisfying.
Nowhere and nothing is perfect, and it doesn’t matter whether you love it or hate it; it’s your obligation to do what you can to make it better. 

Someone sitting in a wheelchair, head slumped forward, snores in agreement.

Chapter 2

Brussels

People need to talk, and people need to listen. In 2019 Harvey gave the world something to listen to.

For thirty-eight years, critical care doctors had been gathering in Brussels every March in the not-quite-thawed tail end of the Belgian winter. This year, terrorist activity in Brussels and Paris and on the train between made the cold city colder.

Dark-uniformed police and military with their grey weapons littered the town and fuelled a mood of uncertainty and apprehension. Despite this, there were more than five thousand people registered to attend the conference – it was huge. And not because doctors from around the world liked the idea of a junket in Brussels – because really, Brussels in March is a hole, with inevitable rain, incessant wind and barely a glimpse of pathetic sunlight each day.

The symposium was, as usual, brilliantly planned and had brought together some of the best and brightest speakers to showcase research, ideas and knowledge from around the world.