Inside The Cut

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. 

Forty-two in the ED waiting room at the start of the shift. What chance do we have to catch up with that?

Mummy it hurts a lot. Don’t worry lovely they’ll be here to look after you soon. 

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

Incoming: three ambulances from an RTA. 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 on the way.

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?

And the intern picked up another crooked arm from the waiting pile. I guess that guy with the headache will be fine.

Paging Dr Goldberg to Resusc. Urgent page Dr Goldberg. Dinner can wait, just like lunch did.

The executive-looking chap with fear all over his face has more chest pain and needs to get to a stent ten minutes ago. Those segments are heading up; look like tombstones.

Three nurses scrubbed and waiting in resusc for the traumas, three more ready to scribe, medical student runners lined up. Lines primed, blood ordered, radiographer on the way. 

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.

Harvey, we may need you in resusc too. No problem, I’ll finish the five things I’m doing in a flash. How does he never get rattled? He smiled at the pale panting old man whose wide eyes and cold hands said it all.

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. EMS and police everywhere.

The first one crashes on arrival, whiter than the sheet, drip tissued, tube down too far – and the dude just 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. Phil hates shifts at triage.

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. His pipe is still hanging out of his jeans pocket.

What do you need me to do? asked Harvey.

Don’t worry about these, says Jess – check the diabetic next door will you and see if those residents in Pod A need a hand. They’re week two and drowning in it.

The adjacent cubicle was frantic with activity. Harvey parted the curtains and stood quietly at the end of the bed surveying the scenario. It was a technique and a discipline that had 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 was always time, there always had to be time, to look and listen and see and hear what was happening. From that would come 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 that white ring around them that 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 which was 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 100% compliant with her treatment (as eighteen-year-olds are prone to be), possibly with an intercurrent chest infection, and with 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 stepped over to stand beside her – an action that 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 minute or three she confirmed Harvey’s end-of-the-bed guesswork. She was on the right track although flustering a bit, so he left her to it, turning back as he moved off 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 and for two hands to meet and interlock. ‘Magic’ he thought; ‘I do enjoy that part nearly as much as nailing the clinical problem.’

They talked for a few minutes and Harvey showed them to the relatives’ room; somewhere they could escape to if they needed to. The fear these parents had was different to the fear they would have for themselves or for each other. More intense, more visceral, uncontainable. 

Harvey wandered off to Pod A and for no particular reason started humming a vaguely remembered aria.

“Don’t ya love Verdi” added the drunk on the bench near the door, with all the staccato impact of a classic De Niro line. Then 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. He probably had a reasonable brain ten years ago. Harvey scratched his head and moved on. I need to get out of here, he thought, 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?

Wide eyes relax. Death. 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 that 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 5, and 200 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 VF scribble via flat-line to something that looks a sick heart.

“What the … who kicked me?” he asked with a dumb-struck look on his face. Winner.

The nurse and the consultant smiled. That was a good one. The medical student stood with her mouth open and thought how remarkably similar that was to an episode of ED.

The psych registrar had arrived and said he was 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.

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.

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 for ever…

Don’t be such a defeatist, said 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. I think he’s being sarcastic – no, his eyes say that he’s serious.

The waiting was over for the girl and her mum, and the injection worked quickly. Her X-ray was fast-tracked and almost before she knew what had happened, a young orthopaedic registrar called Sarah explained about broken bones and straightening them up and plaster and short sleeps. And then she was awake again. Sarah smiled and mum had stopped crying and her arm felt OK. And Sarah drew a big red love heart on the plaster and wrote ‘from Sarah to a brave girl’.

Alison thinks to herself that crying in the toilet cubicle is pathological, but she can’t help herself and just hopes that no one hears.

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 that process along and to turn things in the right direction. The real issue is that all of us know that 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.

© Marcus Kennedy 2020

The moral right of the author has been asserted.

All rights reserved. Except as permitted under the Australian Copyright Act 1968 (for example, a fair dealing for the purposes of study, research, criticism or review), no part of this may be reproduced, stored in a retrieval system, communicated or transmitted in any form or by any means without prior written permission.  All inquiries should be made to the author. 

%d bloggers like this:
search previous next tag category expand menu location phone mail time cart zoom edit close