A day in the life of A&E staff at the ERI

Staff of A&E at Edinburghs Royal Infirmary. Picture: Greg Macvean

He is sitting in the accident and emergency department of the Royal Infirmary of Edinburgh, wearing a tweed bunnet, as insouciant as though this was his local bowling club, and waiting to be discharged into the company of his pal Jock, another bunnet-wearer, with whom he will return to Prestonpans. “I’ll be 80 next month,” he grins, Mr East Lothian Stoicism 2013. “That’s if I make it.”

A few steps away, within a curtained cubicle, a young man in a grey hoodie is pale and sweaty, curled on a hospital trolley, his heart stuttering in irregular rhythms, the result of his having stolen and swallowed the medicine his mother had been prescribed for her psychiatric disorder. Meanwhile, in Resus 2 – one of two large “resuscitation rooms” dedicated to the treatment of the most serious cases – a woman is crying out in pain as nurses cut the clothes from her body; she has been hit by a car in town and has suffered, at the very least, a broken pelvis. Doctors are concerned that she may have hit her head. “Did she bullseye the windscreen?” one wonders, using the mix of painstaking tenderness and blunt slang characteristic of emergency room staff.

Three patients. Three cases. A faller. An OD. A trauma. Three strangers whom fate has brought together here. Each is having a bad day, maybe one of the worst of their life, but for the medical team this is just another shift. Your disaster is their routine. Not that you should think they don’t care. They do, very much. It’s just that they’re used to this way of life and have become intensely pragmatic and understated. They talk not of saving lives but “outcome modification”. They discuss wedding plans while waiting for the ambulance to bring the latest mangled tragedy. They wear Crocs because they wipe clean. “I’ve lost two pairs of trainers to catastrophic bleeding,” says Dr Dave Caesar, the 39-year-old clinical director.

The A&E department of the Royal Infirmary of Edinburgh is the busiest in Scotland. The team treat around 100,000 people each year. Attendances tend to rise sharply from around 11am, and for the next 10 hours new patients arrive at the rate of 20 an hour. More difficult to predict are the variations in “acuity” – the severity of illnesses and injuries; one critically injured patient can divert the staff who might have otherwise been dealing with ten cases, and an incident such as a serious road accident can bring many patients all at once. There are usually around 25 medical staff on shift at the one time.

August is the busiest month of the year, as a result of the festival, but midnight on Hogmanay to midnight on New Year’s Day is the busiest 24-hour period, as a result of the bevvy. Rainy days are busier than sunny days because bad weather causes falls and car smashes, and the wet and cold aggravates respiratory conditions.

Today, there are people with chest pain, folk who have had strokes, and a tough cookie of a school dinner lady with a nasty dislocation to her right elbow which is popped back into place with a loud crack. There is, in the words of one consultant, “a preponderant number of toxicology patients” – those who have taken an overdose of pills, with the intention of either getting out of their heads or out of their lives. But whether you are a junkie or a granny, or both, you’ll get the same level of respect and care. As one doctor puts it, “People just want to know that you give a shit.”

Late afternoon and the black “crash” box within the central administrative area starts to buzz and wail. This is ambulance control phoning to say that the paramedics are on the way. A woman has collapsed. Cardiac arrest. “Crash call,” says a nurse over the tannoy. “Resus 1. Ten minutes.”

A team of seven assembles in the room, and the patient arrives soon after, carried on a stretcher by the ambulance crew. She is moved on to a trolley and the work of attempting to save her begins. What’s striking is the odd calmness of this scene. There is urgency, but no panic, and certainly no raised voices. It could not be more different from the television dramatisations of such situations. These nurses and doctors know each other and this room so well; it would be rather like a family talking quietly at home, getting on with some mundane task, were it not for the woman lying there, being given electric shocks and chest compressions, the orange traces on the monitor showing her life slipping away. “The heart’s trying,” says Dr Caesar. “There’s something there that’s trying to keep going.”

But it is no use. The woman cannot be saved. The senior medic asks her colleagues whether they are happy to stop, and they are. She gives the PLE time – Pronounce Life Extinct – and everyone steps away from what is now a dead body.

No-one wanted this. They did everything they could to prevent it. But it is what happens sometimes. And there are a great many living people just beyond the curtain, all suffering, all requiring attention straight away. If you work in the emergency room you must be able to go from a fatal heart attack to a cracked rib without breaking stride. That’s what it takes. “You’ve got to get your game face back on and get back out there,” Dr Caesar explains. “None of the other patients want to know.”

Screens are wheeled into the corridor so that the body can be moved without being seen. The family of the deceased have to be informed. Alistair Dewar, a 28-year-old specialist registrar who had pumped air into the woman’s lungs as she lay dying, speaks with them in one of the interview rooms reserved for this purpose, known as the “rellies rooms”. He tells them he has bad news and then he tells them what it is.

“It’s never easy to tell somebody that their relative has died,” Dewar explains later. “You just try to comfort them, and reassure them that the ambulance crew and we have done everything we can to ensure their relative has had the best possible chance. It can be difficult when a patient comes in talking to you and then dies under your care. You feel more responsible at that time. I still get affected by it, even though I’ve done this for a few years, especially if there’s something about the family that you can relate to personally.”

A&E is divided into majors and minors. Patients, as they are arrive, are sifted by a nurse into categories of severity – a process known as triage. Even the quiet days are busy. By half-past ten in the morning, all the cubicles in majors were full and patients were being seen while lying on trolleys in the corridor. There are not enough beds in the main hospital to cope with the sheer numbers of patients in A&E who are out of immediate danger but need further treatment. In majors, one patient has been waiting ten-and-a-half hours for a bed. In minors, seven patients have been waiting between eight and 11 hours.

“To a layperson, and to me, that’s unacceptable, but unfortunately I can’t manufacture beds,” says Caesar. “There is no other elastic in the hospital system other than in the emergency department. Nowhere else goes over-capacity in an uncontrolled way other than us, which is a daily frustration of mine.”

A&E is a dramatic place. A tragedy or tragi-comedy behind every curtain. You get the sense, walking from cubicle to cubicle, catching dialogue, of passing from play to play – some absurdist, some desperately sad.

Doctor: “Why did you take the pills?”

Patient: “Self-pity. He had left me.”

Doctor: “Do you want to kill yourself now?”

Patient: “No. Just then. It’s hard to explain.”

One fiftysomething man is here with his sister. He’s been trying to get high on over-the-counter painkillers and has taken them in sufficient doses to give himself internal bleeding. He’s garrulous, gallus; a big fan of TV hospital drama, from which he has picked up a gobful of medical jargon. “My stools,” he informs the doctor with not inconsiderable pride, “are normal.”

His sister, scunnered, cuts in. “Can you not give him something to stop him talking? Not diazepam, though. That’s his favourite.”

It is early evening when I leave A&E. This is a place where you see humanity at its frailest physically, but at its best in terms of courage, compassion, humour and love. A woman has died, a family cast into grief, but many others have been saved, or had their pain and distress relieved. A drama, then, which will never come to the end of its run, but which goes on day after day, night after night, testing the character of its protagonists and offering a reward greater than any amount of applause.

“This job,” says Dr Caesar, “gives you the chance to go home at the end of the day thinking, ‘We made a difference’.” «

Twitter: @PeterAlanRoss