It’s 9.15pm on a Monday evening and my alarm clock has just sounded for the fourth time. Fortunately I am staying in rented accommodation near to the hospital where I work, and I don’t have to think what to wear today (it’s a choice of different coloured scrubs!), so I make it into work in time for my 10pm shift. As usual on my walk to work, I get the pre-shift trepidation, wondering how busy the Emergency Department will be tonight. I count three ambulances parked in the ambulance bay outside the hospital and take a breath – that doesn’t bode too badly. Of course, walking through the waiting room demonstrates that there is a host of ‘walking wounded’, who have come to hospital by means other than an ambulance. I smile at the receptionists and the streaming nurse, who prioritises patients for triage and walk upstairs to leave my coat in the staff room. Someone has left buns for the night shift team – a welcome thought for break time! I walk downstairs on to the ‘shop floor’ and the consultant on duty’s eyes light up and I am handed a set of notes for the next patient who needs to be seen. The consultant will be on the shop floor until midnight and I scan the room to identify my other colleagues on the night shift, heaving a sigh of relief to see my two favourite seniors, who keep me calm in the midst of the most hectic night shifts.
I go to see the first patient, who is an elderly lady with shortness of breath. She does not speak English but her son is with her, translating for us, and I am reassured that she is able to talk in full sentences. She has a background of heart failure and it seems like this is another flare-up. The nurse has already started her on oxygen and I prescribe something to reduce the amount of fluid in her lungs which is causing her breathlessness. Given her frailty and multiple health issues, I decide to ask the medical team to see her, as I think she needs to be observed overnight to ensure her symptoms improve. I bleep the medical SHO – she has had eight referrals already since her handover at 9pm, so I reassure her that I will review the patient before she is transferred to a ward. A nurse approaches me to review an ECG of a patient who had an earlier episode of chest pain, which has now resolved. The ECG shows an electrical pattern called left bundle branch block, which may be significant, if new. To check if it was present on earlier ECGs I enter the patient’s details into the computer and wait for scanned copies of old notes to come up – a very helpful IT system for locating old notes in a speedy fashion. The current ECG is no different to the old, fortunately, so no need to start any immediate treatment, until the patient has been properly assessed. My next patient has had too much to drink and is throwing up. He has a needle phobia and is reluctant to let me put a cannula into his vein for fluids and an anti-sickness injection. One of the healthcare assistants helps me to distract him by chatting about the latest football scores. The senior doctors on duty are busy dealing with a cardiac arrest in the resus area, so I go to find the next patient. Unfortunately there are no free cubicles to see them in. The nurse in charge is as busy as ever trying to sort out those coming in, going home and those being transferred to the ward. There are three patients on ambulance trolleys waiting for a cubicle space to free up, so in the meantime I take their bloods and order basic tests such as X-rays.
One of the psychiatric liaison nurses approaches me to ask if I could do a physical examination on his patient, who had presented with lacerations to her forearms. I use the interview room where she has been assessed in order to examine and treat her wounds, and the psychiatric nurse discharges her with follow-up the next day. The consultant calls me back to the shop floor – a cubicle had opened up and I am now able to see one of the patients from the ambulance trolleys. She is a lady in her early eighties and has a severe infection. I start her on IV fluids and antibiotics and refer her to the medical team. My next patient presents with an eye problem and is able to go home with antibiotic ointment after a slit-lamp examination.
One of the registrars calls for me from the main desk – she needs an extra pair of hands for a log roll, to examine a patient’s spine who has been in a road traffic accident. Two nurses and a paramedic join us to assist. The patient complains of nausea so we keep him on his side with a basin at the ready while the nurse draws up an anti-sickness injection. In view of the mechanism of his injuries the patient is sent for a CT scan of his head and neck to ensure that the impact hasn’t caused a bleed to the brain or a fracture of his cervical spine. I go to reassess the lady with the shortness of breath to find that she had improved and is able to be transferred to the ward. I bring the good news to the nurse in charge who smiles and immediately starts organising for the next patient to take her place.
My registrar approaches me with a smile and says that over 335 patients have come into the department since 9am that morning – that’s a lot of patients for a hospital which only has 500 inpatient beds. He sends me on my break (A&E is one of the few medical departments where doctors have their break times protected) and I go upstairs to hopefully score one of the leftover buns – I am in luck! Another colleague comes into the staff room and we chat about how busy the department has been in the last few months, and how we are always amazed that somehow it keeps ticking over and managing patients within the 4 hour time slot that we are allocated before they have to move on from the department – either sent home, or moved on to a ward.
Back downstairs following a large Diet Coke, my caffeine levels are supplemented and I am ready to see the next patient. It is an elderly gentleman with dementia who has a large pressure sore on his bottom. He lives at home alone, and it seems that his package of care was recently reduced. He thinks that I am his wife and starts to sing me her favourite song, and my eyes well up. I take his hand and tell him thank you, and that he has a lovely voice. I complete my physical examination and discuss the situation with my registrar. This gentleman does not appear to be safe at home with his current package of care. Unfortunately in the middle of the night in A&E there is not much that we can change about his situation so he must be admitted under the medical team for further assessment by the social services team. I am relieved in a few ways – he will be safe overnight in hospital, whereas if he went home he might be at risk of falling or injuring himself. His pressure sore will receive the appropriate wound care. Also he will have some company in the staff and the other patients. The social isolation that we encounter in A&E is very poignant, especially for elderly patients who have lost their spouses and are not able to get out and about as they once used to.
The night continues in this way until at about 4am, the hour that sometimes heralds a brief period of peace or reduced numbers waiting to be seen, an agitated patient in police custody manages to break the glass of the fire alarm. The next 20 minutes cause most of us to have a headache while the fire brigade investigate the cause of the alarm. The last time this happened in my presence was in another A&E department where one of my patients got fed up waiting to see the psychiatric liaison nurse and set fire to a small annex in the department. Fortunately no one was hurt, but I remember feeling cross because I had brought the same patient tea and a sandwich during my break time, indirectly fuelling him to have the energy for arson! For about 10 minutes after the alarm has ceased my ears continue to ring as if I’d been out at a noisy club (right time of the night for it, I guess!)! At 6am one of my favourite nurses is singing a lilting Irish melody – we joke that she has the Going Home Optimism – her shift finishes at 7am, whereas I am not off until 8am. Somehow the last two hours seem longer than the rest of the evening put together. A gentleman comes in by ambulance with an oxygen mask on and a tin tucked under his right arm; he brought biscuits for the staff. We are all overwhelmed. Patients are often kind to us once they have recovered, but to be so unwell and yet stop the paramedics on the way out the door to pick up biscuits for the staff, moved us all. We talked about it for weeks afterwards. At 8am my registrars gave me a hug as we prepared to leave. I have, as usual, left most of my GP letters to the end of my shift, but it always helps me to unwind to think through who I’d seen that night.
You can never leave an A&E shift without a sense that you have achieved something – even if it’s just making sure someone sees the appropriate expert, or is safe to go home. The day team have arrived looking very fresh-faced, ready to take over the constant service that this department provides. I will not be an A&E doctor for the rest of my life, but my medical and nursing colleagues in this field are among the best that I have ever worked with. They are people with initiative, drive and a tireless commitment to the health and wellbeing of patients. They also know how to party on a night out! All in all, it was a good day/night. I go home to bed, ready for the show to start all over again that night.