A night in emergency

It’s called ED. The place people instinctively turn to when they are injured or suddenly ill, and where the doctors are ready for anything. Writer Gary Tippet and photographer Julian Kingma spend a shift at Austin Health’s Emergency Department.

TUESDAY: a wet, grey, cold and miserable day. A day for slips and falls, rear-end collisions, workplace accidents, broken bones and sickness. Yet, at 3pm, the waiting room at the Emergency Department of Austin Health in Heidelberg is little more than half full.

You should have been here yesterday, they say. The place was overflowing, the morose, fidgeting throng stretching along the corridor almost to the hospital foyer. Of course, Mondays in the ED are always busy, with people bringing in the injuries and ailments they have carried through the weekend.

This afternoon, though, is unusually quiet.

Quiet, of course, being a relative concept in a department that on average sees 225 patients every day – 82,074 in the last financial year. Doctors Mani Rajee, Lee Yung Wong and the rest of the staff in Emergency are merely busy – as opposed to run off their feet. Still, most of the 31 cubicles in the department are occupied by patients being treated or awaiting their turn.

In cubicle 26, Lindsay McDonald, 69, of Greensborough, sits with a bandage wrapped around his head. There is sticky blood in his hair and in dried rivulets down both sides of his face. Dr Rajee carefully unwinds the bandage to reveal a ragged five-centimetre laceration, starting above his swollen left eyebrow and running down the side of his nose near his eye.

“Silly accident,” Mr McDonald explains. “Just after lunch today I was shopping, buying a high chair for my granddaughter. I turned around, caught my foot under a cabinet and went down like a … well, like a bag of cement.”

He had a similar fall a week ago. “Got a decent old bump. This one though, there was so much blood it looked like a crime scene where I hit the ground.”

Dr Rajee rebandages him. A cut that deep and so close to the eye means the patient will be going to theatre for plastic surgery, he explains, adding: “This needs to be done properly by the experts.”

Today, Dr Rajee is working in STAT – an acronym explained in a photocopied, pasted-together sign above its inner door: “See, Treat, Assess, Transfer”.

STAT is the second point of call for most people who present at the ED. Initial assessment usually happens at the Nurses’ Triage Station, just off the waiting room, where patients are assigned a rating from 1 to 5 according to the seriousness of their condition and the urgency with which they need to be treated – 1 being the most critical.

Most patients triaged at 1 and 2 will bypass STAT and go straight to the main section of Emergency with its two staff bases, two resuscitation rooms and 23 green-screened cubicles.

In one of those this evening, ED registrar Dr Wong (BMedSc 2007, MB BS(Hons) 2009) meets 67-year -old Maryann Pantalleresco, who, with daughter Tracy, has made a 30-kilometre taxi trip to the hospital from her home at Hillside in the outer western suburbs. They’d have called an ambulance, she says, but knew she would have been taken to a different hospital. And she’s had a long history with Austin Health since a liver transplant here in 1999.

“I hear you’ve had a pretty rough trot,” says Dr Wong.

“Yes, I’ve had the liver transplant, bones broken in both my legs, breast cancer, a thyroid operation, and whatever else there was I don’t remember.”

Mrs Pantalleresco has had almost constant diarrhoea for the past five days. She is very pale, badly dehydrated and close to exhaustion, with pain in the abdomen and lower back, possibly, she says, from a recent fall. She winces and moans softly as Dr Wong presses under her ribs and around her kidneys.

“I worry about her liver and all, her being so dehydrated,” Tracy tells him. “That transplant is the greatest gift I’ve ever gotten,” says her mum.

“I don’t want to have another.” Dr Wong orders blood tests and sets about getting her rehydrated. He’ll be back to see her when the results come back, he says.

TODAY Lee Yung Wong and Mani Rajee are two of the staff – doctors, nurses, ward support staff, clerks, imaging technicians and others – working the afternoon shift in Emergency. The shift is from 3pm until 11pm, but Dr Wong, in blue scrubs, has already been here a few hours covering for a colleague.

Dr Wong came to Melbourne from Kuching in Malaysia in 2004 as an 18-year-old enrolled in the University of Melbourne’s Trinity College Foundation one-year course for high-achieving international students, before joining the Melbourne Medical School. Apart from one year, he has been at Austin Health since his internship there in 2010. After enjoying a few rotations through the ED, he began emergency medicine training in 2013.

“There’s something attractive about doing a small thing that has a big impact in a great time of need.”

As someone who likes to work with his hands, he says he toyed with doing some surgical training, “but maybe my attention span was too short”. The ED offered a similar chance of hands-on medicine as well as offering constant variety and immediacy.

“We’re generalists,” he says. “We try to care for the patient as a whole and I think that’s a good quality of emergency medicine.

“People are usually in a great deal of pain or distress when they come to Emergency. I like the fact that you can still do a lot for them. There’s a really short space of time in which you can do a really great intervention – whether it’s just listening to someone or giving them medication or pain relief. There’s something attractive about doing a small thing that has a big impact in a great time of need.”

Emergency physician Dr Rajee is Clinical Sub-Dean in Emergency Medicine at the Austin Clinical School and the University of Melbourne Faculty of Medicine, Dentistry and Health Sciences. But before coming to Australia 23 years ago, he had never worked in an emergency department. In Chennai, in southern India, he had been an ear, nose and throat surgeon.

“When I started, it was very, very interesting,” he says. “It was a new field and you had a chance to do everything. You could do some surgical work; you could do some medical work. You got to see everything – the good, the bad and the ugly.

“You can’t get bored. You might deal with a heart attack, then all of a sudden it’s a kid with a broken bone or someone with a stroke. You see every type of patient, the young, the old, male and female, cuts and lacerations, serious infections, people dying in the department.” At Footscray Hospital years ago, he even delivered a baby in the ED.

But there are frustrations, he adds. Increasingly, people are using the ED like a general practitioner’s clinic for relatively minor ailments. There are drunken and drug-affected patients and staff face abuse and even violence. It is why the staff in the triage area now work from behind glass screens like those in banks.

“Emergency is stressful but also very satisfying,” says Dr Rajee. “You have some gift that you’ve learned and you can use it to help other people in critical times. It’s a nice feeling if you’re helping another human being in need. That is the greatest feeling.”

The ED can be challenging and often confronting, adds Dr Wong. But one of the attractions is working in a big team responding to those challenges.

There is enormous camaraderie in Emergency, he says, a strong, positive, supporting culture. “When something major comes through those doors and you see everyone switch on and chip in and work together, that really is a sight to behold.

“I think for most people doing emergency, including myself, I don’t think we can see ourselves doing anything else. There’s a small caveat to that – it’s a tough job to do full-time, for your whole life.”

THE NIGHT grinds on. Doctors Rajee and Wong tend to a constant stream of the injured and the ill.

In cubicle 30, 81-year-old Giuseppe Prestileo waits with his wife, Caterina. Nine years ago, he was treated for prostate cancer and now uses a catheter every two days “to clear the way”.

He tells Dr Rajee: “I put it in today and I think I went too far. I’m urinating blood, blood with my wee. Too much blood.”

After a bladder scan and some hydration, his home diagnosis is confirmed: he has scratched inside his bladder. He is catheterised and the urine dripping into a bag gradually turns from deep red to a light rose tinge. But he’ll spend the night in the short-stay unit.

In an examination room, plumber Graeme Davis’s left knee is sore and badly swollen. He was putting up some guttering yesterday when the ladder slipped and he rode it to the ground. X-rays show a fractured patella, an ultrasound confirms there is no bleeding in the joint, and a 3D scan reveals in detail the break, which looks like a slightly tilted capital F.

The good news is that it won’t require wiring and Graeme goes home in a Zimmer splint stretching from his upper thigh to lower calf.

Meanwhile, Fiona Turner, 31, has arrived at Staff Base 2. Dr Wong lets second-year medical student Richard Cole, on his first shift in the ED, question her. Fiona tells him she has been persistently unwell since a bout of influenza two years ago, has had gastro problems and has been on antibiotics since May.

Very pale and in tears, she says she has a band of severe pain stretching around her abdomen: “It’s like labour pain, but you probably wouldn’t understand how that feels.” Richard correctly suggests she may have colitis, perhaps from too many antibiotics.

Back in STAT, 63-year-old Helen Nikolaou presents with severe tonsillitis and asthma, and a temperature of 38.6. Later, her husband, Chris, arrives in a wheelchair from Austin Health’s Olivia Newton-John Cancer Wellness and Research Centre next door, where he has been having radiation treatment for thyroid cancer that has spread to his brain, lymph nodes and lung.

“They’ve told me that without treatment I’d have 14 weeks; with treatment 16 months, maybe longer,” he says. He suspects Helen’s worry for him has worn her out.

Helen will be admitted, but for his own good Chris has to leave, says Dr Rajee. “Because he is having radiation treatment he really needs to stay away from someone with a serious infection.”

 

They keep coming: 17-year-old Angus Garrard has broken the fifth metacarpal in his left hand after crashing his trail bike into a kangaroo at Hurstbridge; he goes home in a plaster cast. Adele, 31, receives eight neat stitches to seal a cut in her forehead suffered in a fall at a supermarket.

A scientist, who has had long-term eye problems including glaucoma and is on the waiting list for a second cataract operation, presents with a bad bleed in his right eye. A victim of a massive stroke passes away in a resuscitation room.

Late in the shift, Dr Wong bends over a computer screen and shakes his head. Mrs Pantalleresco’s lab results are back and one number worries him.

Her level of creatinine – a chemical waste product usually filtered out through the kidneys – is at 398 when it should be less than 100. Six days of diarrhoea seems to have shut down her kidneys. She may be headed for intensive care.

He goes to see her: “I’ve got some news for you and it’s not good. We have done the blood tests and you are in kidney failure.”

“Oh, lovely,” she says. Her daughter begins to cry.

“It’s all right, Trace,” says her mum. “And anyway, we’ve got two kidneys, haven’t we? It’s just another word on my long list – kidneys.”

Dr Wong says they will now admit her and begin treating and rehydrating her. “That’s good,” she says. “I know I’m always in good hands when I come here.”

Emergency medicine was not recognised in Australia until 1993, nine years after the Australasian College for Emergency Medicine was formed.

“Before then,” says Dr Thomas Chan (MB BS 1991), Director of Emergency Medicine at Austin Health, “emergency was predominantly staffed by junior doctors with oversight from various specialties that lent their expertise depending on the situation.”

Under the so-called Anglo-American model of emergency care, emergency departments are now staffed by specialists with a range of core skills and training in evidencebased pathways to evaluate a range of patients.

“There are many demands at that coalface,” says Dr Chan. “Time pressures; the ability to think on your feet is important; there are the demands of shift work; and the ability to prioritise your clinical demands and to make sure not only are patients diagnosed correctly but that they are identified as either potentially deteriorating or otherwise.”

It is also vital to discern the social or underlying factors behind a patient.

“The ED is the front door,” he says. “When there’s no one else a patient can go to, be it medical or social, they come to the ED because we’re open 24/7.”