Mark O'Neill has been an emergency department nurse for eight years, and the job is as hectic as ever. Picture: Nick Bradshaw
My day kicks off at 6.30am. I cycle to a job I love. Everyone that I work with loves their job.
There’s no team like the team in the emergency department (ED). It’s not a place where you can coast, or where you would even want to coast. Staff in the ED have a different mindset. We’re all there to treat the sickest patients. If you want a less frenetic nursing environment, you steer clear of the ED. There are other options, like the calmer atmosphere of a nursing home.
My shift starts at 7.30am. There are three separate areas in the ED: ‘Triage’, where patients are prioritised for treatment based on clinical need; ‘rescus’, or the resuscitation/trauma area, where staff carry out life-saving procedures; and ‘majors’, where seriously ill patients receive more thorough assessment and treatment.
Examples of majors include chest pain, difficulty breathing, abdominal pain, and neurological complaints. Patients with less serious conditions are sent to a ‘minors’ area. These might be patients with fractures, dislocations, or cuts that require a few stitches.
Most people assume that we deal mainly with major trauma, but, in reality, we see more patients with a medical illness. The numbers coming in due to trauma have reduced; some of it’s down to people being more diligent about wearing seatbelts, some of it’s due to improved vigilance vis-à-vis health and safety on building sites, and some of it is just down to people being more sensible about their behaviours when it comes to protecting their health.
Once the night staff have completed their handover, myself and my colleague in triage get stuck in, while, over in ‘majors’, about 25 patients are waiting to be seen, a really mixed bag of injury and illness.
There’s a 17-year-old with appendicitis, a 90-year-old woman who has broken her hip, a man in the palliative care stage of cancer and in dire need of pain relief. Some have been there all night. On a bad day, 10-15 patients will have been there overnight. We triage the patients, working our way through the list, but, before long, we are feeling the squeeze, as more and more patients arrive.
Typically, activity starts picking up from 8am and, by the time it peaks around lunchtime, you could be talking about a new patient arriving every five minutes. That would be normal. They come at us from all angles — those who walk in off the street, those who arrive by ambulance, those who were attending an outpatient clinic and have been referred by their doctor for admission to hospital via the ED. They present with a very broad spectrum of injury and illness and our job is to make sure the sickest are treated first.
In theory, this is the sensible approach. Those with life-threatening conditions need to be prioritised. But with just two of us triaging growing numbers of patients, things start to slide.
That’s actually the worst part of the ED, the everyday stuff, where you literally can’t get to people to look after their basic human needs. You know there are people here for hours and they haven’t eaten. You know bedpans need to be changed. You know people are in pain and that all they require is a couple of painkillers, but you can’t even get to do that. You literally have to keep going with the triaging, just to keep the system going.
The pressure to stay on an even keel means simple actions, like having time to chat with a patient, are also out the window. This is very tough on them and soul-destroying for us. We’re supposed to be a caring profession and people come to us at a time when they are feeling low. They’re not in peak condition. They need our help. They want to be reassured.
They’re worried about chest pain, about abdominal pain, about severe headaches. The various diagnostic tests are done and the patient is given the results. But that’s it. There’s no time for a chat or reassurance, or to explain why it was necessary to carry out the tests. There’s no time to educate them about maintaining their health going forward. It’s not fair on them and it’s frustrating for us. Part of healthcare should involve educating people about how to stay well.
The food situation in EDs is absolutely horrendous. People can spend a few days on a trolley and never actually get a hot meal. In any ED you go into, you can be sure people have gone hungry and been left in pain or in the cold. It shouldn’t happen in a first-world county, that basic human needs are neglected.
People need to go to the loo, but you are tied up assessing a new patient and they end up soiling themselves. You don’t get to change a bed pan on time. You don’t have to be a nurse to acknowledge that this is wrong. From a human dignity point of view, it’s horrific.
But the reality is while you are trying to make sure one patient is fed and reasonably comfortable, three or four more have arrived and so you find yourself doing the minimum — checking to see if a patient is in immediate danger, and, if not, moving on. In reality, the only time this practice should apply is in the event of a major disaster.
Our major-disaster training teaches us to assess the patient’s condition, stabilise those who need to be stabilised, and move on. But this is not the way the system is meant to work every day in the ED. The unpalatable reality is that it is exactly how the system works.
Mondays are particularly chaotic. By midday on Monday, we could have 100 patients. It is not unreasonable for them to be accompanied by at least one family member or friend.
People need this kind of support when they are unwell. But if each of those 100 patients has just one companion, we are then up to 200 people in the ED, in addition to staff, trolleys, and lots of medical equipment. We are then getting to the point where the logistics of getting them through the ED is becoming impossible. There are more people outside cubicles than in.
The number one concern this raises is the heightened risk of people spreading infection. Then, there’s the knock-on effect on patient assessments. There is zero privacy. The reality is that with 10 people within earshot, patients can be reluctant, or embarrassed, to tell you what is wrong. This can result in poor assessments. It makes it more difficult to deliver a diagnosis.
It means people are longer in the ED. We have too many patients to assess and we can’t move them through quickly enough. We end up shooing out family members and relatives. As triage times start slipping — our target is to see people within 10 minutes of arrival, but it’s regularly stretched to an hour — there’s a knock-on effect on ambulances. We can’t take patients from our ambulance colleagues and a queue of ambulances starts to form.
As they wait around, emergency calls start to back up. We spread ourselves thinner and thinner. We try to organise for those who are not acutely unwell to be transferred to less acute hospitals. Another portion gets admitted to our hospital. But they keep arriving. Our normal day is not delivering basic care, but trying to stop conditions worsening. Unfortunately, the pressure we are under means patient reviews are not always done in a timely way. Delivery of treatments and antibiotics are delayed. People get sicker.
Can I tell you how many times this has happened? Could I say if patients have died because we didn’t get to them on time? It’s very hard to say, it’s so subtle. If I’ve had 100 occasions when I should have given antibiotics sooner, then I could definitely say some of those people got sicker.
But it’s very hard to prove it was due to ED overcrowding. As a nurse, you’re trying to act as a safety net and not let anyone slip through, but there is only so much a person can do.
Do people get annoyed with the treatment delays and the failure to cater for basic needs? Of course.
Everybody gets annoyed. It’s like we have the same conversation all the time. At this stage, my response is almost automatic: “We’re doing our best, we’re under-resourced, we’ll get to you as soon as we can.”
You can’t get annoyed back. People are ill. You can’t get upset at someone demanding pain relief for their elderly mother. At this stage, apologising for how bad things are is part of our daily dialogue.
At the end of the day, people coming in have a good idea of what to expect, which is a sorry indictment of the mess our EDs are in. At times, they are quite understanding. They read about it every time they open a newspaper. “I’ve heard about it, but I didn’t know it was this bad,” they say.
Some surprise me, because they come in with no notion of how bad things are. People with private health insurance can get upset because they are paying €3,000-€4,000 a year for healthcare and they find themselves waiting in a long queue. But, in the ED, everyone is equal. In the public system, people are treated on need and not ability to pay.
Most people recognise that you are doing your best. They realise you really have no control over the system. But you do get physically and verbally abused. I’ve been pushed and shouted at, particularly where there’s alcohol involved. Or, sometimes, where mental illness is a factor. The chaos of the ED is not the best environment to calm things down. In saying that, a lot of people have the impression EDs are full of drunks and junkies. That is not the case. It’s much more nuanced than that.
Working in the ED eventually gets too much for most. Everyone who leaves always asks: “Is it any better? I’d go back if it was better.”
That’s the feedback I get from colleagues in Saudi, Australia, the UK. They all want to come back to Ireland, but they work in EDs with reasonably good working conditions, so where’s the incentive? I’m as senior as it gets now in the ED, after eight years. Everyone else has gotten out.
What qualities do you need to work in an ED? You need to want to solve problems and solve them quickly. There are new challenges, not just every day, but every 30 seconds. We tend to thrive on hard work. We are confident and driven, from a knowledge point of view. We are motivated to learn. But things are so bad at the moment, morale is so low, that that kind of enthusiasm tends to ebb away. And that kind of motivation is not something Health Minister Leo Varadkar can dole out. It’s intrinsic to the job, but it is slowly being killed off.
My shift is scheduled to end at 7.30pm, but, in reality, it’s 8.30pm. I head home on my bike. Do I bring the day’s problems home with me? If I’ve had a particularly stressful day, it can be hard to switch off. I replay situations. I worry about things I didn’t get done. I end up ringing in sometimes to make sure something I didn’t get to has been looked after.
Is it physically draining? Some days. But it’s emotionally draining every day. You’re going solidly for 13 hours and there are times when I get home and all I want to do is sleep.
Catherine Shanahan
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