He gets up and he stumbles into the shower and then dresses up for work. An orange vitamin pill is all his breakfast, and he drives to work, still half dazed. It is a Saturday morning on a long Easter weekend and the roads are clear. As he approaches the hospital, he notices that his tank is almost empty and he pulls into the nearby Shell station.
He pays for his petrol with his credit card but in his half awake state he pulls out the card too quickly. TRANSACTION CANCELLED. He tries the card again. CARD DECLINED. He smiles apologetically to the counter girl and pays by eftpos. 'Looks like you could do with more sleep,' she laughs.
And So It Begins
No sooner had he hit the department, waiting for handover when an overhead announcement is made. 'Level 2 trauma, Resus 2, Emergency Department.' He pokes his nose into the cubicle and sees that his boss is already there with another morning registrar and some lingering night staff.
The patient is a young gentleman who had been T-boned by a car on the highway when he was pulling out. He was in a neck collar and the consultant was moving an ultrasound over his tummy to see if there was any internal bleeding.
The boss quickly confirms no bleeding, and tells the doctor to take over from there while he runs handover. The doctor quickly checks the patient over, and confirms that he is stable before getting bloods from him. The nurse hands him a syringeful of blood which he proceeds to fill the tubes with. He is still waking up, and pulls the plunger a little too eagerly, which disconnects from the syringe. The blood goes everywhere onto the trolley.
He lets out a curse and somehow manages to salvage some enough for all the tubes. The nurse with him is a friend, and kindly cleans up the mess without telling him off. The blood is all over the trolley, and had made its way into the trolley, staining the packages holding the cannulas with blood. She disposes of the contaminated packages and cleans up the trolley.
After The Blood Bath
The ambulance warning system beeps through. A young guy was coming in, who was found by bystanders to be running down the streets half naked, screaming his head off before collapsing into a heap. The department prepares itself for the arrival of the patient, and he is soon wheeled through. He is in a drug daze, and barely rousable. His pinpoint pupils suggest that opioids may have been involved.
They give him some reversal for the opioids but he does not wake. His level of respiratory depression means that they need to put a tube down his throat to protect his airway while waiting for whatever drugs he had taken to naturally work its way out of his body.
You comfortable to do the tube? his boss asks.
His mind says no.
Yup, he says.
They get everything ready for the intubation. The patient was going to be a difficult one. Short neck, retracted jawline, overriding teeth. The patient is put into an induced coma. The intensive care team arrives, and there is suddenly an audience of about ten people.
Have a look now, his boss says.
The doctor brings the laryngoscope into the mouth of the patient. He attempts to find the patient's vocal cords, but is having a little trouble finding it. Pull back, says the intensive care consultant. Take your time, says his boss.
He sees the tip of the vocal cords but couldn't get it to lift. Nope, not seeing it, he says, his hands shaking with the weight of the laryngoscope blade.
The boss steps in and takes over. A few experienced maneuvers with the laryngoscope and suddenly the tube is down the throat, and the chest rises and falls as he bags the patient.
You just needed your blade to be more secure, the boss tells him gently in front of his audience. The doctor knows he is still learning and will keep getting better at this, but couldn't help feeling deflated for not getting this tube.
******************************************
The day passes on with a few more dramas, a sixty year old man who had collapsed out the front triage after having a huge vomit of blood and a few more overdoses and road accidents customary to the long weekend. Among them all were the minor irritations of the arguments with the radiology registrar about getting scans, trying to convince sick patients wanting to self-discharge that they needed to stay, and trying to juggle all the patients under his care and remember what he needed to do for who next.
He is due to leave at six that evening. A new patient was coming in after an overdose. He was drowsy and combative, and he was huge.
Two policemen and another two ambulance crew were in attendance, as the patient was struggling in his half drugged state, potentially a threat to his own safety and that of others. He had written a clear suicide note that evening and had taken eighty of his antipsychotic medications wanting to end his life.
They put him into a resuscitation cubicle and strap his arms and feet down so that he doesn't hurt himself. His evening boss walks in and decides, We need to tube him.
The doctor tries to find a vein to put a cannula into but has little luck. Everything he touched that day was turning to whatever the opposite of gold was.
His colleague finds a vein on the other arm, and they place the patient into an induced coma. Another colleague, a registrar slightly junior to him manages to intubate the patient successfully, and the doctor watches with a mixed sense of pride and a tinge of envy.
The Opposite Of Gold
The patient is prepared for intensive care. A catheter is put in to measure his urine output and his evening boss puts him in charge of putting in the nasogastric tube - a tube that goes into the patient's stomach in order to drain out any secretions and prevent it from going into his lungs.
The doctor struggles with the nasogastric tube. It goes down a distance but not as smoothly as he would like. You sure you in the stomach? his evening consultant says with a querying smile.
Well, it's gone in a distance... the doctor says, but he knew that the resistance he had felt with the nasogastric tube going down was not a reassuring sign.
They try and check if they are in the stomach. They take a huge syringe and try to aspirate out some stomach content. Nothing. They try and blow in some air while a nurse listened for sounds in the stomach. Nothing.
Well, an experienced nurse offered, we can check if it's bubbling. It was old school but it sounded like a plan. They brought a kidney dish of water and place the other end of the nasogastric tube into it to see if it would bubble, suggesting that it is in the lung.
It does not bubble.
Still not convinced, the evening consultant calls for an X-ray which would show them for sure the position of the nasogastric tube.
The X-ray returns. The nasogastric tube... is sitting in the right lung. Somehow it had made its way past the ventilation tube straight into the right lung. See? said the consultant, smiling. Told you it wasn't in the stomach!
They pull out the misplaced nasogastric tube and the consultant has a go at putting it in. He struggles as well, and gives up after a few attempts.
Let's get an art line in, he says. They try to get a needle into the patient's radial arteries to see what his blood pressure is doing. The doctor can feel a good pulse on the left wrist and has a go at it, but misses despite several attempts.
His consultant tries on the other wrist and misses as well. All this time the emergency department is still running and getting busier behind the curtains.
This is not a good day for lines, his consultant says, looking a little deflated himself. I'm going to have to come back and try a little later. I've got a department to manage.
He walks away and leaves the doctor to himself, whose bleary eyes looked up at the fuzzy numbers reading 7:45 pm, one hour and forty five minutes after he was supposed to have finished, and sighs while he stubbornly tried to find an artery on the patient's right wrist to put a needle into.
Another senior registrar walks in after he has had a few more attempts. H has told me to come in here and see if I can help you with this art line, she says. She puts on a pair of sterile gloves, feels for a pulse, inserts the needle and suddenly there is a satisfying gush of blood into the needle. She effortlessly threads the needle, secures the line and attaches the monitoring.
Guess he likes girls more, she smiles.
The doctor stands there and smiles in return, shaking his head a little. He cannot believe how easy she made that look, but was more relieved that the line was finally in.
She waltzes out of the room and leaves the doctor and the two nurses who are bustling around the resuscitation cubicle getting all paperwork sorted out, preparing the equipment to move the patient into intensive care.
The Road Not Taken
The doctor leans against the table in the cubicle, and stares blankly into space for awhile. His stomach rumbles as he finally remembers he hadn't eaten all day.
He smiles to himself and to a day that has defeated him, and he says aloud, to no one in particular, Today, I want to be a baker.
The nurses, who have worked with him so long that they were more like friends, let out a laugh in agreement as they knew exactly how he felt about the day he was having.
He leaves the department with a sigh. He will take the long drive home and he will tell his loving partner about the unbelievably long and crap day he's had, and then he will sleep, because tomorrow he must return.
*******************************************
He thinks about his previous Emergency Department director, who was like a mother to him in his workplace, and who was instrumental in him choosing Emergency Medicine as a specialty.
He remembers her hand on his shoulder after another particularly difficult day like today, and her voice still rings clearly in his ears - Just remember, you're gonna good days and bad days, young Dr. Heng, so don't take it too personally, all right? Press on, because you are a good doctor and don't let it get to you.
Tomorrow he will be better.
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