March 1, 1997
Twelve hours in Halifax Emergency Room.
ROBERT J. MOHL
News Editor
ROANOKE RAPIDS -- It's Friday night in the Emergency Room of Halifax Memorial
Hospital and Dr. Singh has arrived.
Dr. Anant B. Singh, 48, of Rocky Mount will run the ER for the next 12 hours.
He's an employee of Southeastern Acute Care Specialists, which runs the ERs of
HMH and Nash General in Rocky Mount.
"It's not an ER. It's an ED," corrects Singh. ED stands for Emergency
Department, but most of his staff calls it the ER.
Dr. Ted Westover is getting ready to turn the ER over to Singh. He's been on
since 7 a.m. and the day has been "pretty steady." A lot of older patients with
pneumonia. One death from cardiac arrest. Westover updates Singh on the patients
still here.
"We try to not have too many patients turned over," Singh says.
At 7 p.m. there are six names on the board used to keep track of patients.
Dr. Westover and his staff are leaving. A nurse is updating the names on the
staff board. Now it's Singh's ER.
Singh is at the doctor's station in the middle of the main desk, dictating
his notes over a telephone after treating a patient. His pace is fast and
clipped.
The charge nurse, Cindy Jones, is on the radio talking to an incoming
ambulance, writing vital signs onto a chart. The ambulance is one minute from the
hospital.
"Ten-four," says Jones, 29, of Roanoke Rapids. "Give you bed 5 on arrival."
The charge nurse runs the ER with the physician.
"We pride ourselves on being part of a team," Singh says. "Some areas are
predominantly doctor's, some tasks are predominantly nurse's. In between is a lot
of gray area ... Everybody pitches in."
"I'd be totally lost without my nurses," says Singh. "There's a lot of
camaraderie, we count on each other."
Singh has five nurses to count on. Four staff nurses and a triage nurse. The
triage nurse decides who goes to the ER and who goes to the Convenient Care
Center, or CCC. The CCC is for lesser problems and is staffed by a physician's
assistant and another nurse.
The good old days
The double doors fly open and paramedics wheel a patient into a curtained
observation room. Behind the curtain the nurses change the patient into an
examination gown, get a medical history, take vital statistics and make her
comfortable.
"In the good old days a patient was admitted, then triaged," says Singh. "Now
it's the reverse because the government's worried about wallet biopsies" --
checking out patient's financial resources and prescribing treatment based on it.
"Now the patient is being triaged, prepped and registered concurrently,"
Singh says. Patients no longer come into the ED with complete charts. Getting
that information quickly is critical.
The doors fly open. Before they can ask, Jones tells the HEMSA personnel
"Room 8."
"We usually get 30 patients a shift," says Jones while she updates her
paperwork. "It's about the same all the time, unless we get a disaster."
"The toughest part for us is trauma patients, being a small hospital," says
Jones, . "For a hospital our size I think we do a good job."
On an ordinary night the ED has five nurses total. On a trauma case, you need
three nurses per patient.
If swamped the hospital has private physicians on call. In an emergency they
can airlift patients by helicopter to larger hospitals in Greenville, Durham and
Chapel Hill.
Candidates for evacuation include "multiple system trauma" and head injuries
requiring a neurologist's attention.
"Most hospitals have a trauma unit," says Jones. "But not these small
hospitals."
Then she's off to answer the radio. Another patient is coming in.
Working at warp speed
The ER is white and gray, looking like any modern office. On the walls are
white boards listing the physicians on call and the status of the examination
rooms.
Exam rooms, 16 in all, fill up most of the department.
Then there are the trauma rooms. Trauma 1, 2 and 3 are the largest rooms --
reserved for "code" cases involving heart attacks, auto accidents, gunshots.
"They are big rooms, good light, they are stocked very well," says Singh.
One of the rules of the ER is always keep a trauma room open. You never know
what's coming in.
In the middle of it all is the main desk, equipped with a TV screen to
monitor the psych ward and a monitor that relays the rate and rhythm of patient's
hearts.
"Every heartbeat is monitored," says Singh.
It's 8 p.m. and there are 8 names on the board. All the observation rooms are
full, and Singh is busy.
A 47-year-old female has had stomach pain for the last three days. Singh
peppers her with questions: How long have you been throwing up? How's your bowel
movements? When did the diarrhea start? Other than diabetes and hysterectomy, any
other medical problems? Ever drink? You smoke? Married, widow?
"Frances, all charts and EKG on patient in 9," orders Singh. He shoots out
orders: foley, IV Zantac and others too fast to follow. Too fast unless you live
and work at these speeds.
The next patient is a 68-year-old female who slammed her leg in a car door.
On the way there a nurse asks about yet another patient. Singh approves her plan
and dives in.
"Interruption is a fact of my life," says Singh.
Another rapid fire examination. Singh gives the woman, with daughter in
attendance, a quick lesson in the circulatory system and why it's too late for
stitches. He prescribes a bandage while he washes his hands and is complimented
on his beard.
"That's the great thing about this job," says a charged Singh. "You meet all
kinds of people."
He returns to dictate his notes on the last two patients, and is called away
to attend to another incoming patient.
No one turned away
If information is the blood of the ER, Frances Carroll of Gaston is the
heart. As secretary it's her job to provide the doctor with patient records and
to order labs. She also answers the phones and "anything the doctor throws at
me."
"I have to sometimes answer three people at the same time," Carroll, 52, says
as Singh bursts from behind a curtain asking for charts and history.
The ER sees 32,000 patients a year -- 95 a day split evenly between day and
night shifts. The staff remembers when they treated 95 in one shift.
The ER gets a stabbing or shooting once a week, a trauma case once a day.
Fifty to 80 percent of visits to the ER are not "true emergencies." Screening
them is the job of the triage nurse.
"When a patient comes in, if they are walking or talking, I decide if they
are emergency, urgent or non-urgent," says triage nurse Melanie Barber, 34, of
Roanoke Rapids.
In her office, Barber gets a description of the problem, takes vital signs
and a medical history. She also does first aid, cleans wounds, prescribes
Tylenol. She sees 30 to 50 cases a night.
So far she's seen three sports injuries and a parade of colds, nausea and
vomiting.
"A lot of people come here instead of going to see their doctor," she says.
"Some of them say they've had a cold for two hours. We had a 16-year-old call an
ambulance because he had a cold. He just jumped out the back."
New parents are also found at the Emergency Room. For them normal infant
things, like crying, take on menacing proportions.
"We say for emergencies, but people around here don't know. To them it is an
emergency," says Barber.
"We can't turn anyone away," says Singh. "Even if we construe it as a
non-emergency case. Even if we feel they are overusing or abusing us."
It's 8:35 p.m. There are ten names on the board.
Quiet night
"This is a quiet night," says nurse Steve Barnes, 42, of Jackson as he spins
away to answer the radio. "We have 10 names, that's manageable. I've seen 25
names, that's bad."
It's a slow night, but not slow enough. Dr. Hector Manlapas has been called
in.
Manlapas, an internal medicine specialist at the hospital, covers the
emergency room for 24 hours, twice a month. He's one of about a dozen names on
the board, ready to assist the ED.
"It's not unusual to be called in," he says as he studies a chart of a
pneumonia victim, one of several he's treating tonight.
It's now 9:22 and there are 11 names on the board.
Singh, dictating behind the desk, springs up and chats with a woman being
discharged with a sinus infection.
Then it's off to the back, where a 69-year-old man is in pain.
"Oh god oh god oh god oh god," he whispers over and over.
Singh is trying to get the man's list of medications from his daughter. He is
fast, asking his next question the millisecond she finishes answering the last
one.
His questioning is a physical thing: he jumps, he snaps, he wrestles the
answers onto the chart. They are the same questions asked by any doctor, but
compressed into a tenth of the time.
It's not enough. Singh thinks it might be a kidney infection, but he needs to
know more. He hands the chart to an EMT student with a message to get a blood
sugar test.
Singh's patients have a litany of problems. Underlying the immediate ailment
they have diabetes, kidney problems, heart problems- masking their symptoms and
complicating treatments.
To avoid dangerous drug interactions he needs to know everything they are
taking. For some patients it's a long, long list.
Singh prescribes an antibiotic for a 4-year-old girl with an ear infection.
He slows down around kids, but makes up for it outside the treatment room.
Walking fast, he goes to the board and draws a red arrow through the name,
marking her as discharged. Now there are six patients, at 10:36 p.m.
Not for long. Six minutes later, two ambulances are coming in. An asthma
attack and somebody with leg pain.
Adrenaline junkies
Why the manic pace?
"I like to be busy. Most cases are non-mundane. You don't get bored," says
Singh. "When I'm off, I'm not on call. I get to spend quality time with my
family."
Singh works two to five ER shifts a week, days and nights.
"I like variety. It makes you think," says Barnes, the nurse from Jackson.
"The ER expects you to use your training. There's only two doctors on a shift."
"I couldn't do anything else," adds nurse Brenda Lane, 38, of Murfreesboro.
"I went to a nursing home. It was too slow."
"Somedays you don't want to go, but then you stay home and wonder what's
going on, she says. "I love it. It's satisfying, real satisfying."
What do they have in common?
"They like that kind of work," says Singh. "They don't mind working in
chaotic conditions. Some of them are adrenaline junkies, they don't mind their
attention being drawn in different ways."
Still, there is a cost.
"The burnout rate is high," says Singh.
Fewer than 50 percent of emergency medicine specialists are still in the
field after 10 years.
It's 11 p.m. and the convenient care center has closed down. Physician's
assistant Doug Milroy, 45, of Rocky Mount, has come over to lend a hand. About a
third of the patients at the ER are sent to the CCC.
"I don't want to sound bad, but it's to get stuff out of the emergency room
that doesn't belong there," says Milroy. He's handled about 20 cases, including a
nasty wrist fracture on his shift. "An average day," he says.
It's 11:45 and there are 11 names on the board. A woman waiting to be
admitted to HMH coughs behind a curtain. Family members sit quietly at bedsides,
asking the nurses for blankets every now and then.
"Sometimes it's dead quiet. Usually there's three or four patients here all
the time," says Barnes.
"For now it's quiet. It's not always," says nurse Lane. "When it gets quiet
you get that feeling, that feeling all over. That's the quiet before the storm."
No TV anecdotes
At 1:50 a.m. the last four names are being discharged. For the first time
since Singh got here, the ER is empty. Nurses are hunched over, clearing out the
paperwork that built up during the evening. Everything is quiet except for the
beeping of an unplugged heart monitor.
One has to wonder, What do they think of "ER" on television?
"I've never watched the show," says nurse Barnes. "No TV show gets it right.
I feel like screaming 'you're doing it wrong.'"
"We don't watch it," said nurse Judy Williams. "We'd be at work."
Singh watched it once and says it's the closest to real life, but won't watch
it again.
"You ever hear the phrase I gave at the office?"
He's had a brush with stardom though. The emergency room physicians who are
consultants to ER sent him a letter asking for anecdotes and story suggestions.
He threw the letter away.
"They should never have called it ER," he says.
It's 3 a.m. The ER is still empty. This is the slowest time, when Singh gets
caught up on his newspaper and medical journal reading. The nurses stock
supplies, clean-up and get organized for tomorrow.
Singh, relaxed, talks about his time-share condo with a visitor from
radiology. The nurses fill out paperwork, or take the time to read. The lights
are turned off to save power, giving the ER a larger, more mysterious look.
At 4:30 a.m. a mother brings in her 2-year old daughter who has an ear
infection. Singh is done in two minutes, prescribing antibiotics.
At 5 a.m. another mother comes in. Her 3-year-old boy has stomach pains.
Singh rules out appendicitis, prescribes Tylenol for the stomach, and antibiotics
for bronchitis. By 5:13 a.m. the mothers have left and all is quiet again.
Things pick up at 6 a.m. Three patients come in. Chest pain in 5, another in
10, and leg trouble in 4. Singh speeds up again.
He rules out a heart attack on a 34-year-old male and then goes to see with
63-year-old woman. She is as pale as a ghost, suffers from diabetes and has a
heart condition; but that's not why she's here.
A tree fell on her knee when she was chopping it down, she explains.
"Why were you chopping down trees?" asks Singh.
"They were in my way," she says.
The right leg is obviously broken, and the woman is confused about dates. He
suspects senility, but worries that a kidney problem could be causing the
dementia. He's also worried about her pallor. He orders blood tests and X-rays.
"So sad," he says, heading for a 71-year-old woman in 10 with headache and
chest pains.
The woman with the broken leg has a low blood count, but normal. Her kidneys
are also fine. Singh exchanges a few words while she is wheeled off to radiology
and decides to extend his shift until the X-rays get back.
"She's a sweet old lady. I hate to turn her over to anyone else," he says.
It's 7 a.m. and the sun is coming out. A nurse is writing down the names of
the new shift workers, erasing the old ones.
And another night in the ER comes to a close.
(
geocities.com/rjmohl)