Going Under

by Sonia Henry

  ‘Urghhhh,’ she moans, her head lolling to the side.

  Her friend, not quite as smashed but swaying next to her, looks at me. ‘Are you a nurse?’ she slurs.

  Ignoring the question, I ask the girl who’s vomited, ‘Have you taken any drugs tonight? Or just booze?’

  ‘Just booze,’ she mutters. ‘Can’t you give me something to stop me being sick? Aren’t nurses meant to help people?’

  ‘There’s a girl vomiting outside,’ I inform the triage nurse as I swipe myself in. ‘She’s conscious but she’s pretty drunk.’

  The triage nurse rolls her eyes.

  ‘Booze, apparently,’ I say, pointing to the front door.

  ‘Tell the paramedics inside,’ the triage nurse says flippantly.

  I sigh.

  ‘Drunk girl outside the front door vomiting everywhere,’ I tell the ambulance guys hovering by the main desk. ‘I’d get her in here, but I think it needs man power.’

  At least the paramedics don’t argue. Nurses are a different story.

  The relationship between doctors and nurses is a tricky one. There’s this misconception that everyone should feel sorry for nurses, and the doctors are always the bad guys. We are, members of the general public tell me, overpaid, arrogant and difficult to deal with. Nurses, conversely, are underpaid and overworked, and always seem to make the patients feel so much better. I hear people say all the time in social settings that their medical team ‘did nothing for them’ (aside from saving their life), but the nurses, ‘well, they were lovely’. There are even bumper stickers that say: BEHIND EVERY DOCTOR IS A SKILLED, INTELLIGENT NURSE SAVING THEIR ARSE. Of course, these are treacherous waters I’m entering—saying anything less than positive about nurses is sort of like saying anything less than positive about Nelson Mandela.

  On that note, I walk into the department to meet the consultant on the floor that evening for a quick orientation, and within the first five seconds she’s warning me that the nurses in the emergency department are extremely territorial. ‘The best thing to do,’ she advises, ‘is to just let them boss you around for a while. I’m not sure why they’re like that, but if you resist they can make your life very hard.’ Then she laughs a bit nervously—this consultant emergency physician of over twenty years’ experience—leans in and says, ‘But for God’s sake, don’t tell anyone I said that.’

  It takes about two days working in a public hospital as a junior doctor to realise that nurses love nothing more than bitching about how useless we are, how much more experience they have, how they always know better than us, but in the end it all comes down to one sticking point.

  When a nurse doesn’t know what to do … they call a doctor.

  When a nurse needs a medication charted … they call a doctor.

  When the patient’s blood pressure drops even slightly … they call a doctor.

  When the nurse makes a mistake and starts panicking … they call a doctor.

  When someone makes a mistake and it ends up in court, the person who takes the stand will inevitably be … the doctor.

  On an evening shift on the ward, a nurse of ten or more years’ experience still looks after the maximum of four or five patients. A doctor in their first week of training is looking after three wards—maybe a hundred and ten patients.

  Emergency nurses, I realise about two hours into my first night shift, are particularly problematic. They have more skills than ward nurses, which gives them more confidence. The nice ones are a dream to work with. The not-so-nice ones add another layer of anxiety. In the eyes of emergency nurses, all new junior doctors are put on trial. Apparently, they give you a month and then, if they decide they don’t like you, they refuse to help you. With anything. The Godfather slept with the wrong nurse early into his emergency term and he paid for it until his last shift.

  ‘Katarina, your cannula field isn’t clean enough,’ Mandy, the head nurse in emergency, snaps as she picks up the cannulation equipment I’ve arranged in order to stick a drip in a seriously dehydrated patient. ‘I’m throwing it out. Get yourself another one and I’m going to watch and see that you’re doing it properly.’

  ‘Maybe you can put the cannula in, Mandy,’ I suggest. ‘I’ve got five patients at the moment and one is about to go into theatre.’

  ‘I’m not up to date with my accreditation,’ she says smugly, ‘so you have to do it.’

  Nurses love not being up to date with their accreditation, which is an excuse not to work. Doctors don’t need to be accredited or taught new skills. We’re just expected to learn on the job.

  ‘It’s all right, Kitty.’ James, one of the other doctors, appears next to me. ‘I’ll do it for you.’

  He rolls his eyes as Mandy storms off in a huff, annoyed that I have managed to avoid her on-the-spot cannulation assessment.

  ‘Thanks, mate,’ I say, feeling grateful I am on with decent doctors tonight. ‘Appreciate it.’

  It’s nearly midnight, and James and I still have a good nine hours ahead of us. Maybe tonight there won’t be many patients, I think hopefully.

  I walk around the corner to have a look in the waiting room.

  Every chair is full. Some of the people waiting try to catch my eye. Their expressions are angry, as if saying, ‘We know you’re a doctor—why haven’t I been seen yet?’ I feel my stomach clench.

  When Max did his emergency term, he told me, he started altering his opening line when he saw patients. ‘If they look well and the triage says they’ve come in for something like, I don’t know, elbow pain they’ve had for a year, I used to open with: “Good evening, I’m the doctor seeing you tonight. What is your emergency?”’

  I like that. ‘What is your emergency?’ I practise, trying not to sound as passive aggressive as I am feeling.

  I walk back to the main department, where the doctors on the shift before mine are finishing up, leaving me, James and Matt, the senior, on overnight.

  ‘How’s it been?’ I ask one of the doctors who’s about to leave.

  He shakes his head ruefully. ‘Have you seen the waiting room?’

  I nod. Have I ever.

  ‘Yeah, it’s been fucking shit,’ he tells me, suppressing a yawn. ‘Sorry to leave you with it.’

  ‘It’s all right,’ I say. ‘It’s not your fault.’

  ‘A patient told me tonight if I missed his vein when I cannulated him that he’d kill me,’ the doctor tells me. ‘I said, “Is that a threat on my life, sir?” And then I missed his vein anyway.’

  We both laugh, even though it isn’t that funny. If someone makes a threat like that on a flight, they’ll be arrested. But threatening a doctor inside an emergency department while they’re trying to help you is apparently nothing to worry about. People probably think it’s a good thing; it might make us work faster.

  Our hospital is, apparently, the best-performing emergency department in the state. It’s debatable what this actually means. To the hospital board, it means that we’re the best at meeting the government’s arbitrarily created key performance indicators. Some genius, in all their wisdom, has created a timeframe called ‘the four-hour rule’. If a patient isn’t seen, reviewed, assessed, investigated, diagnosed and then treated or admitted to the ward in less than four hours, we’re informed by the ‘emergency department navigator’ that ‘we have breached’. The emergency department navigator is a nurse whose sole role is to harass the doctors on the floor when they fail to meet the timeframe. To ensure maximum humiliation, they call your name over a loudspeaker so the entire department knows you’re going too slowly.

  ‘Katarina, to the navigator’s desk, please.’

  They don’t give two shits that you’re seeing three or four patients at any given time, that most or all of them have something complex wrong with them, that you’ve called about a million specialists to come and review them but they’re all stuck on the ward or in theatre. All that matters to the navigator is that every patient is either cured or at least shipped into an ove
rcrowded ward within two hundred and forty minutes.

  ‘Kitty, can you pick up the ear pain in the waiting room?’ Matt asks me as I stare at the computer, trying to figure out which will be the least taxing patient. ‘He’s been here a while …’

  He clicks my name off before I can respond, as if I actually have a choice, and I trundle into the waiting room to meet Jason, a thirty-seven-year-old male with a sudden onset left ear problem.

  ‘Jason?’

  Two men stand up, one looking pained. Jason, I discover, has brought along a friend, who happens to be a private ENT surgeon.

  ‘I’ve already assessed him,’ the surgeon tells me as I faff around asking Jason if he has any allergies. ‘He’s got sensorineural deafness. He needs to be admitted under ENT and given IV steroids, now.’

  ‘Do you have admitting rights at this hospital?’ I ask him hopefully, praying that he does and that I can fast-track an admission and avoid any awkward confrontations.

  ‘No,’ he says, looking annoyed, ‘but it doesn’t make any difference. That’s what he needs.’

  I examine the patient and quickly establish that Mr Private ENT Surgeon is indeed correct: Jason does have sensorineural hearing loss and does require urgent IV steroid therapy, stat.

  ‘I think he needs to be admitted under ENT,’ Mr Private Surgeon advises me for the third time.

  I agree with him. I run it by Matt, who tries to bluster around the issue for a while, because no one likes being told what to do by other doctors on their own turf, but the outcome is inevitable.

  ‘You’re going to have to call ENT,’ he tells me gloomily.

  Reflexively, I check the time. It’s 1.20 am. I swallow. If a patient has to be admitted or there’s a problem that can’t be solved by the emergency doctors, it means waking someone up and asking what to do. And even though senior specialists or their registrars are listed as on call overnight in case one of the emergency doctors needs some urgent advice, what ‘on call’ really means is: I’m asleep. In bed. If you call me and wake me up, I’LL BE VERY FUCKING ANGRY.

  My stomach, irritatingly, clenches slightly at the thought of making the call. But no one in the best-performing emergency department in the state knows the correct dose of dexamethasone to administer for this kind of problem, so I really have no choice.

  I call through switch. ‘Can I have the ENT registrar, please?’

  ‘Sure, love,’ says Susan, who’s on switch tonight. Then, ‘Oh, it’s Dr So and So.’

  ‘Is he mean?’ I ask with trepidation.

  Susan sighs. ‘Good luck, love,’ she says. ‘Putting you through now.’

  ‘Wait!’ I shout into the phone, panicking wildly, but it’s too late; the phone is ringing. I’m committed.

  The ringing stops abruptly, and I hear mumbling, like someone trying to wake up, then, ‘Yes? What do you want?’

  ‘Ah, hello. I’m so sorry to call you at this hour. I’m one of the junior doctors in emergency, and I have this patient …’

  ‘What?’

  ‘Ah, do you have a moment to discuss a patient?’

  ‘It’s one o’clock in the fucking morning!’ the voice on the other end of the phone exclaims, sounding seriously annoyed. ‘Why are you calling me at one in the fucking morning?’

  Maybe Susan has put me through to the consultant, not the registrar. Maybe there’s been a mistake and this person isn’t even on call. Maybe this is a complete misdial, and this person isn’t even a doctor but a complete random whom I’ve woken up in the early hours of the morning.

  ‘Sorry, are you the ENT registrar on call?’ I ask.

  ‘Yes,’ the voice says flatly.

  ‘Oh, right.’ I’m relieved. ‘Look, I know it’s a bad time to call, I’m really sorry, but it’s kind of a touchy situation. This thirty-seven-year-old guy has come in with sudden onset hearing loss in his left …’

  ‘You’re calling me at one in the morning about hearing loss?’ the voice interrupts me, dripping with disgust. ‘What kind of idiot are you?’

  ‘It’s sensorineural deafness!’

  ‘Give him some fucking steroids!’

  ‘How much?’

  ‘You’re a fucking idiot! Don’t call me again and don’t admit him under us! He’s not coming in under ENT!’

  ‘If you could tell me the dose …’ I plead, but it’s to no avail; I’m now speaking to a dial tone.

  I put the phone down. The waiting room’s full and I still don’t know what dose of steroid to give my patient.

  I quickly wipe away the tears that have sprung to my eyes. This is no time for crying.

  Matt walks over. ‘How’d you go with ENT?’ he asks.

  I clear my throat. ‘He wasn’t very interested,’ I confess. ‘He said we couldn’t admit to the ward under ENT. What should I do?’ I’m wondering how I’m going to tell Mr Private Surgeon that his friend isn’t going to be admitted under ENT.

  ‘Well, admit under ENT, obviously,’ Matt says cheerfully, patting me on the back. ‘That’s why they gave ED direct admitting rights.’

  I try not to think about the ENT registrar’s reaction when he arrives on the ward tomorrow morning to find I’ve admitted the patient he refused to discuss. I decide to make my signature extremely hard to read in the chart so he won’t know what my name is. The reason why doctors have such messy handwriting suddenly becomes crystal clear.

  ‘What dose of steroid should I start him on?’ I ask.

  Matt doesn’t know.

  ‘His surgeon mate would probably know,’ I say.

  ‘Maybe just ask him,’ Matt says finally.

  I walk down to the bed where my patient and his surgeon are waiting to see what will happen next.

  ‘I’ve spoken with ENT,’ I say, forcing a smile, ‘and we’re going to admit you.’

  Mr Private Surgeon looks satisfied.

  ‘So we’ll just, ah, start you on the IV steroids now,’ I add, my confidence faltering. I hold the medication chart and a pen. ‘Just out of interest,’ I say awkwardly, ‘what dose of dex do you think you’d start on?’

  ‘Oh, fifty milligrams,’ the surgeon says, seeing straight through me, ‘but it depends on what you want, of course.’

  ‘Just what I was thinking!’ I exclaim enthusiastically. ‘Very good. Ah, good.’

  I quickly chart the fifty milligrams of dexamethasone and tell the nurse in charge to get Jason to the ward as quickly as possible.

  I look at the time: 2.30 am. Nothing stops the clock, I remind myself. As bad as things can get, nothing can stop the clock. In seven hours, I’ll be crawling into bed.

  I walk into the waiting room and call the next patient.

  ‘Just come with me, I’m one of the doctors on tonight,’ I say, forcing a smile.

  The patient gets up, swaying. She glares at me. ‘Well, it’s about time, you motherfucker!’ she declares loudly before falling over.

  I’m so tired I don’t even blink. ‘I’d probably prefer it if you called me Katarina,’ I say, grabbing her under one arm and hauling her off the floor.

  Nothing stops the clock.

  thirty-eight

  The weeks in the emergency department, while stressful, move quickly. It might be the odd shifts or the fast pace, but it starts to feel as if I’m going to sleep, waking up, going into the emergency department, then going home. During my runs of night shifts I lose contact with my friends aside from the odd text and spend daylight hours in a chemically induced coma before waking up in the dark to go to work.

  I emerge from my stupor only briefly to a text from Wolfgang Dietrich informing me that he and Tomas have booked their flights to come to a conference in Australia and they are looking forward to the dinner I promised them. I feel forgotten emotions of excitement and happiness, and file this information away, telling myself that when the run of night shifts ends I will patch things up properly with Winnie and also tell her the good news that we will be hosting a dinner party. For now, though, it’s back to the gr
ind.

  As I drag myself through the front doors of the emergency department at eleven for a night shift and see, yet again, the packed waiting room, I realise that most patients have zero idea of what constitutes an emergency.

  Emergency means life-threatening anaphylaxis. Emergency means high-speed motor vehicle accident and abdominal trauma. Emergency means suicide attempt and huge drug overdose with acute liver failure. It doesn’t mean a mild tummy ache that could be cured with Panadol, or a mosquito bite.

  It occurs to me that there are a lot of very sad and unloved people in society for whom coming into the emergency department means that, at least for a little while, someone will care for them. I develop this theory as I sit in one of the assessment rooms five hours later, as the clock ticks over to 4 am, listening to the woman in front of me cry about her hip, which has been hurting for seven years.

  Something breaks inside me.

  ‘Look, Sandra,’ I say, interrupting her long story, ‘what’s really going on?’

  Most of the time they just want someone to talk to. Sandra came into the emergency department consciously seeking medical care but subconsciously seeking something else, something that I can’t give her and something that no hospital can provide.

  There are so many lonely people in this world. Their loneliness shrouds them, so they become invisible. They’re in the corner of your eye, hovering in the periphery. Yet we always miss them—sometimes even when they’re sitting right in front of us. For every attention-seeking time-waster who floats through the doors of the emergency department, there’s another patient, invisible, who slips in between them. I’m always meeting these people at 4 am, I think sadly, hearing these stories when we all should be peacefully asleep in bed.

  ‘I think my husband is cheating on me,’ Sandra says, and starts to cry. ‘And I’m scared I’ve got herpes.’

  I take a look. Sandra is right. She has such a severe case of herpes she ends up being admitted under gynaecology for pain management. I write her up for regular morphine, feeling guilty.

  People say you see life when you experience certain things. When you travel around the world, or get married, or have a baby. But the most I’ve learned about life has been while working in the emergency department in the early hours of a Tuesday morning. We’re always told in magazines and online and in movies that life is this endless notion of possibility. We dream of the adventure, but we live a different sort of reality. The kind of reality that walks into a hospital at four in the morning. At 4 am in the emergency department, people feel like they don’t need to pretend anymore.